Effect of a multifaceted intervention on the utilisation of primary health for maternal and child health care in rural Nigeria: A quasi-experimental study

Objective The objective of this study was to determine the effectiveness of a set of multifaceted interventions designed to increase the access of rural women to antenatal, intrapartum, postpartum and childhood immunisation services offered in primary healthcare facilities. Design The study was a separate sample pretest-post-test quasi-experimental research. Setting The research was conducted in 20 communities and primary health centres in Esan South East and Etsako East Local Government Areas in Edo State in southern Nigeria Participants Randomly selected sample of ever married women aged 15-45 years. Interventions Seven community-led interventions implemented over 27 months, consisting of a community health fund, engagement of transport owners on emergency transport of pregnant women to primary health centres with the use of rapid short message service (SMS), drug revolving fund, community education, advocacy, retraining of health workers and provision of basic equipment. Primary and secondary outcome measures The outcome measures included the number of women who used the primary health centres for skilled pregnancy care and immunisation of children aged 0-23 months. Results After adjusting for clustering and confounding variables, the odds of using the project primary healthcare centres for the four outcomes were significantly higher at endline compared with baseline: antenatal care (OR 3.87, CI 2.84 to 5.26 p<0.001), delivery care (OR 3.88, CI 2.86 to 5.26), postnatal care (OR 3.66, CI 2.58 to 5.18) and childhood immunisation (OR 2.87, CI 1.90 to 4.33). However, a few women still reported that the cost of services and gender-related issues were reasons for non-use after the intervention. Conclusion We conclude that community-led interventions that address the specific concerns of women related to the bottlenecks they experience in accessing care in primary health centres are effective in increasing demand for skilled pregnancy and childcare in rural Nigeria. The study was conducted in two rural LGAs (Esan South-East and Etsako East) in Edo State, Nigeria from December 2015 to November 2020. Nigeria is made up of 36 States and a Federal Capital Territory, Abuja. Each State consists of LGAs, and each LGA is further divided administratively into political/health wards, and a ward comprises several small communities or villages. Edo State is one of Nigeria’s 36 states located in the South-South region. The State has an estimated population of 4.7 million in 2020 and 18 LGAs.20 The study was conducted in two of Edo State’s LGAs identified above. Both LGAs are located in the riverine areas of the state, adjacent to River Niger with Estako East in the northern part of the Edo State part of the river, while Esan South East is in the southern part. The two LGAs have a total population of 455 432 persons, with Esan South East accounting for 241 492 and Etsako East LGA accounting for 213,940.20 Nigeria operates a three-tier healthcare system with primary healthcare as the entry into the health system, the secondary health facilities also called general hospitals and the tertiary/teaching hospitals at the apex. The secondary and tertiary hospitals are referral hospitals. The country has a functional referral system with the conditions for referral clearly specified in the protocols and manuals that guide service delivery at the lower levels of care.13 21 The PHCs are controlled by the LGAs, whereas the Federal Government controls the tertiary/teaching hospitals. Presently, Nigeria has 40 338 operational hospitals and clinics, and 85% are primary healthcare facilities and many are privately-owned health facilities, where routine, basic and comprehensive emergency obstetric care services are offered.22 Nigeria has one of the largest stocks of human resources for health in Africa with a doctor and nurse/midwife population ratio of 38.9 and 148 per 100 000 population, respectively. These ratios are far above the sub-Saharan African average of 15, and 72 per 100 000 population for doctors and nurses, respectively.23 PHC workers typically consist of one medical officer if available, one community health worker who must work with standing order, four nurse/midwives, three community health extension workers (CHEWs) who also must work with standing order, one pharmacy technician, six junior CHEWs who must work with standing order, one environmental officer, one medical records officer and one laboratory technician. Support staff includes two health attendants/assistants, two security personnel and one general maintenance staff.13 The principal sources of maternity care in the two LGAs are PHCs. However, Esan South East LGA has one general hospital in Ubiaja (headquarters of the LGA) while Etsako East has one General Hospital in Agenebode (the LGA administrative headquarters) and another in nearby Fugar City. Several private hospitals also exist in both LGAs that offer maternal and child health services of various degrees of quality. The study was a pretest–post-test, quasi-experimental design. The study was conducted in three phases: pretest (baseline), intervention and post-test (endline). A baseline mixed-method research comprising a household survey with ever-married women aged 15–45 years was conducted from 29 July to 16 August 2017. The intervention was implemented simultaneously from January 2018 to March 2020 (27 months). At the end of the intervention, an endline household survey was conducted between 24 June and 6 July 2020, using the same study instrument, to evaluate the effect of the intervention. The effect of the intervention was measured using a household survey with ever married women aged 15–45, at baseline and endline. At baseline, eight wards were randomly selected from the 20 wards in the two LGAs, and 20 communities (also regarded as clusters) were randomly selected from the eight wards. To maximise local efforts and for ease of management, the intervention was limited to two of the eight baseline wards. The two wards have 31 communities and four PHCs. The sample size at both baseline and endline was 1318. To adjust for non-response, 10% was added to derive a sample size of 1450 (725 per LGA). At baseline, twenty communities (also regarded as clusters) were randomly selected from eight wards in the two LGAs (10 communities per LGA), and a total of 1408 women were successfully interviewed from 3462 households in these 20 communities. The details of the sampling technique have been described elsewhere.16 After the intervention, an end household survey was conducted with a separate cluster sample of ever married women ages 15–45 in 20 communities. A total of 1411 women were successfully interviewed from 3116 households in the 20 communities. The eligibility criteria were ever married, had a birth in the 2 years before the end survey and was not a respondent in the baseline survey. The aim of the intervention was to increase women’s access to skilled pregnancy and child care. The baseline research identified the factors that limit women’s access to skilled pregnancy care. Subsequently, the results were shared with community stakeholders, who then advised on appropriate interventions to address the identified bottlenecks. The implementation of the intervention activities was led by WDC whose members were selected by the traditional rulers and key decision-makers in the communities. One of the WDC members serves as the chairperson. The WDC is an initiative of the Federal Ministry of Health to oversee the activities of primary health centres in the political/health wards in Nigeria.24 25 Seven intervention activities were implemented as described below following the TIDieR checklist. Anchored on the three-delay model, the interventions were designed to reduce the barriers to utilisation of skilled care provided in PHCs. Each intervention activity was monitored during the intervention using appropriate process indicators. This was a local community fund-raising and contributory insurance named ‘Igho Omoh’ (meaning ‘money to protect the child’) and ‘Ikpagie Omo’ (meaning ‘financial savings for the child’) that enabled participating pregnant women to obtain treatment at PHCs without being deterred by an inability to pay. Pregnant women registered with payments of a total of ₦2000 (US$5.26), which could be paid in instalments. A registration card was issued to the women which contained details such as name, address, contact details and those of her partner, the telephone numbers of the WDC chairman and the rapid SMS keyword and telephone number. A community-level fundraising activity took place bi-annually to support the scheme. Women who registered in this fund were entitled to free delivery care, which cost about ₦4500 (US$11.84) on average for normal delivery and to access the transportation and rapid SMS interventions. A total of 765 pregnant women registered in the fund during the intervention. The funds were paid into a bank account held by the WDCs, while monthly reporting of the proceeds of the account was made to all members and the traditional leaders. This was to address barriers due to lack of transportation. The WDC registered interested transport owners and committed them to make their transport services available to pregnant women in case of an emergency. The specified rates were paid from the community health fund by the WDC at the end of the service. This was widely advertised and used during the period by pregnant women in the communities. This is real-time two-way communication between a pregnant woman in distress, the WDC chairman and the PHC nurse, using a mobile phone. The woman triggers an alert system by sending a keyword to a phone number configured to a central server. The woman gets automated feedback from the server to wait. At the same time, a dual SMS with the woman’s name and address is relayed to the WDC chairperson and the nurse, reporting an emergency. The WDC chairman calls one of the registered transport owners to pick up the woman, while the nurse prepares to receive her. Telephones were given to the WDC chairperson, the nurse in charge at the PHCs and to a few pregnant women who had no telephone. The women and their partners were taught how to use Text4Life during registration in the community health fund, and antenatal care visits. A drug revolving fund (DRF) was set up for each of the four project PHCs. The WDC members and the project PHC providers were trained by the Edo State Ministry of Health on the techniques of managing a DRF. This ensured the availability of essential drugs in the project PHCs at affordable prices. Initial funds were provided by one of the community leaders to start the funds. The returns were paid into the WDC project bank accounts, from which replenishments of stock-outs were made periodically. Community sensitisation and health talks led by the WDC took place regularly in the project communities. The WDC members were taught by the project technical committee to implement the health talks, some of which took place on a house-to-house basis. We also produced and distributed informational materials to women and their families on the importance of using PHCs during the talks. An advocacy team was set up to identify stakeholders in the communities and government. The aim was to sustain the project’s results through community commitment and ownership and policymakers’ active support. The team paid advocacy visits to the Deputy Governor, the Federal Ministry of Health, the Edo State Ministry of Health and to LGA Council chairmen. It was such advocated visits that resulted in the allocation of more nurses and midwives to the PHCs, the provision of support funds to the project from various leaders of the community, for example, for the construction of a residential quarter for doctors, the donation of two mobile ambulances and the donation of equipment and facilities to the project PHCs. Nurses and midwives in the PHCs were given regular training on basic maternal and child care. This consisted of hands-on quarterly training on safe delivery using the WHO guidelines of PHC delivery, the demonstration of vaginal delivery, proper management of the third stage of labour and the resuscitation of the newborn. We also taught the parthographic management of labour and the points at which women with prolonged labour should be referred to secondary care facilities. Also, delivery kits were supplied to the PHCs; mattresses, bedsheets and pillows were replaced in the PHCs, where these were either lacking or worn out; functional tricycles were provided by the LGA for transportation and referral of women, and personal protective equipment was supplied to the four PHCs at the time of out-break of the COVID-19 pandemic. The same pretested household survey questionnaire was administered face-to-face by trained field assistants using computer-assisted personal interviewing (CAPI) at baseline and after the intervention. The questionnaire consisted of five sections. Section 1 contained the respondents’ sociodemographic characteristics; section 2 was on partners’ and other family characteristics, section 3 contained questions on the respondents’ reproductive history, section 4 was on antenatal, intrapartum and postnatal care experience for pregnancy and births in the preceding 2 years, and immunisation for children age 0–23 months. Section 5 contained questions on barriers to utilisation of PHCs for maternal and childcare. The WDC was involved in the intervention design and implementation. The outcome variables were the use of a PHC in the project wards for skilled antenatal care, delivery care, a postnatal check-up for mother and child and any of the recommended immunisation for the children age 0–23 months for the respondents’ most recent birth 2 years before each survey. The use of a PHC in the project wards was coded 1, whereas the use of other facilities was coded 0 for each of the four outcomes. The explanatory variable was the survey period indicated as baseline and endline. The baseline was the reference category. Drawing from previous studies and theoretical perspectives on the utilisation of maternal and child health services,26–30 some individual and family-level factors were added to control the likely effect of any variation in the characteristics of the respondents at baseline and endline. The control variables included age recorded in single years, the highest level of education (no education, primary, secondary, higher), access to the media. A measure of access to the media (more, less and no exposure) was generated by aggregating the responses to the frequency of listening to the radio and watching television. Religion was categorised as Catholic, Other Christian, Islam, Traditionalist and others. Due to small numbers, Islam, Traditionalists and others were merged for the multivariable analysis. Other characteristics were work status categorised as working and not working; age at marriage in single years; marital status categorised as married, living together and formerly married (widowed, divorced and separated); type of union (monogamous and polygynous) and LGA. The respondents were also asked their most important reasons for using or not using a PHC for skilled care. Multiple response options such as the cost is too much, providers are not available and quality of care among others were provided. The data were extracted from the CAPI device into SPSS V.20, and Stata V.13 was used for analysis. The characteristics of all the respondents at baseline and endline and the prevalence of the outcome variables were described using frequency, percentage, mean and SD where appropriate. The difference in the outcomes between the two periods was presented as the difference between the percentage at baseline and the percentage at endline. An assessment of the significant difference in the characteristics of the respondents at the two periods was conducted with a t test for continuous variables, and a test of association for categorical variables using χ2 and Fisher’s exact test, where the assumptions for χ2 was not met. All the frequencies in the distribution of the study population by the outcome variables do not total to 1408 (baseline) and 1411 (end line) due to non-response. To determine the effect of the intervention on the utilisation of PHCs for maternal and child care, binary logistic regression was conducted with the survey period as the explanatory variable adjusting for clustering at the community level, and individual and family characteristics of the respondents that may have influenced change between baseline and endline. The respondents’ sociodemographic and family characteristics were adjusted in the logit model. The result of the multiple responses to the most important reasons for the use and non-use of a PHC for delivery care was compared between baseline and end line. Each reason for use or non-use was generated as a dummy variable with yes as the positive response and no otherwise. A test of association was conducted using χ2 or Fisher’s exact test where appropriate, for each reason and the survey period (baseline and endline). P values from these tests were reported with the frequency of the positive response to each reason and the corresponding percentage of the total number of respondents at endline who used or did not use the PHCs in the project communities, excluding non-response. The level of statistical significance in all the statistical tests was set at ≤0.05 (95% CI and all p values were two sided).