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Background: Maternal and infant mortality remains high in Nigeria primarily due to low use of skilled birth attendants. Huge disparities exist between southern and northen Nigeria on use of skilled birth attendants with south significantly higher than the north. We assessed the effect of centering pregnancy group (CPG) antenatal care on the uptake of antenatal care (ANC), facility delivery and immunization rates for infants in Kano state. Methods: Between December 2012 and May 2014, pregnant women with similar sociodemographics and obstetric history were enrolled into intervention (CPG) and control groups and followed up prospectively. Chi-square tests were conducted to compare the differences between the intervention and the control groups with respect to background characteristics and intervention outcomes. Logistic regression was used to measure the associations between CPG and uptake of services for mother-baby pairs in care. Results: A total of 517 (260 in the control group and 257 in the CPG) pregnant women enrolled and participated in the study. Thirty-six percent of women in the control group attended ANC at least once in 2nd and 3nd trimester compared to 49% of respondents in the CPG (p < 0.01). Health facility delivery was higher among CPG (13% vs. 8%; p < 0.01). When controlled for age, number of previous pregnancies, number of term deliveries, number of children alive and occupation of respondent or their spouses, respondents who participated in the CPGs compared to those who did not, were more likely to attend at least one antenatal care (ANC) session in the third trimester [adjusted risk ratio (ARR):1.52; 95% CI:1.36-1.69], more likely to immunize their babies at six weeks [ARR: 2.23; 95% CI: 1.16-4.29] and fourteen weeks [ARR: 3.46; 95% CI: 1.19-10.01] and more likely to use health services [ARR: 1.50; 95% CI: 1.06-2.13]. Conclusion: Centering or group pregnancy showed a positive effect on the use of antenatal services, facility delivery and postnatal services and thus is a promising intervention to increase uptake of maternal health care services in northern Nigeria. The low facility delivery remains a cause for alarm and requires further investigation to improve facility delivery in northern Nigeria.
Kano State is situated in the North-West of Nigeria and administratively divided into 44 Local Government Areas (LGAs). It is the most populous northern state with a total population of 9.4 million people of which 4,627,556 (48.3%) are female [23, 24]. Women of child-bearing age (15–49 years) account for about one-fifth of the total population, while the number of pregnant women (5%) in the state translates to about 478,280. The study was conducted in Kura Local Government Area (LGA) of Kano State, Nigeria, a largely rural community between December 2012 and May 2014. Kura LGA had a projected population of 175,200 with 38,544 women of childbearing age and 8760 pregnant women. Four intervention community clusters in Kura LGA were selected for the establishment of the centering pregnancy groups (CPGs). The intervention community clusters were selected based on having a health facility where deliveries were taken to ensure that requisite staff (nurse/midwife) and infrastructure for delivery was available. Each community cluster had a complement of four CPGs – for primigravida, multigravida, grand multigravida and postnatal care. The purpose of segregating pregnant women into groups defined by age bands and number of pregnancies was to facilitate peer-to-peer interaction during the CPG sessions by eliminating the cultural expectations of deference to older people, which would be a significant barrier to open interactions. Thus, a total of 16 CPGs were created as intervention groups. The CPG curriculum was based on a community-validated facilitative approach, which incorporates locally-rooted cultural concepts, language and practice. The CPG curriculum was adapted from a group pregnancy care model by the Population and Reproductive Health Initiative (PRHI) of Ahmadu Bello University, Zaria, Kaduna state. The CPG curriculum is divided into 11 modules of which eight modules are focused on antenatal care and three modules on postnatal care. During the CPG facilitated sessions, discussions on pregnancy, childbirth and newborn care related topics were guided by a CPG curriculum and basic clinical antenatal care was provided. Topics discussed included knowing your body, common discomforts in pregnancy, nutrition, hygiene, danger signs, birth preparedness, safe delivery, breastfeeding and baby care. In addition, malaria, HIV/AIDS and family planning were discussed. The CP model used in this intervention differed from the standard group ANC approach used at most Nigerian health facilities in the following key respects: (i) an educational format is followed that uses a facilitative leadership style with didactic discussion format; (ii) each session has an overall plan; (iii) attention is given to core content although emphasis may vary; (iv) there is stability of group leadership and the composition of the group is stable, but not rigid; (v) participants are involved in self-care activities and opportunities for socialization are provided and there is ongoing evaluation of outcomes. Each CPG was facilitated by a team of Community Health Extension Workers (CHEWs). In Nigeria, CHEWs are trained to provide education on pregnancy, manage ANC, recognize signs of labour complications and coordinate referrals for complicated pregnancy but do not undertake labour and delivery services. The CHEWs were trained for three days on the CPG curriculum and facilitation skills before commencement of the intervention. They also had five one-day refresher trainings during the intervention. The CHEW teams were trained and supervised by Obstetricians and Pediatricians from PRHI. Each team consisted of three CHEWs with one acting as the team leader. In addition, each session had a facilitator and a co- facilitator who had different roles: the facilitator introduced the topic for the session, the women facilitated the discussion; and the co- facilitators noted the group dynamics and contributed whenever an important issue in the module was left out or inadequately addressed. The women in each CPG were approximately around the same gestational age hence, the group sessions were scheduled based on the traditionally practiced antenatal care follow-up pattern in Nigeria: monthly visits till 28 weeks of gestation; fortnightly till 36 weeks; and weekly till delivery. After delivery CPG members were required to attend postnatal CPG sessions at 2, 4, 6, 10 and 14 weeks post-delivery in addition to home visits conducted by the CHEWs. The CPG sessions were held at the primary health clinic or center located in the community and each CPG session lasted about 3–4 h. To limit any selection bias, other health care facilities that conduct deliveries within the community clusters were identified. Pregnant women who received regular antenatal and postnatal care at these facilities were identified and recruited as the control group with similar stratification as those in the intervention group. Standard antenatal and postnatal care at health facilities in the LGA had the similar follow-up patterns as described above for the CPGs. Due to the stratification of pregnant women enrolled in the CPGs by parity, along with the limitation in the number of study sites to work in, randomization at the individual or community level was not possible. Rather, a quasi-experimental non-equivalent groups design was used to to select participants while enabling assignment of study participants by facility catchment to pre-defined study arms. Using the formula for comparing two proportions, a total sample size of 268 per study arm was required using an ANC utilization rate of 50%, a design effect of 1.5, attrition rate of 20% and level of precision of 0.05 to detect a 15% difference between the intervention group and control group. In anticipation of possible early dropouts and early deliveries (the gestational age at enrollment was based on client self-reports), a total of 587 clients were enrolled into the study. To be eligible for participation within both intervention and control arms of the study, pregnant women had to be 15–49 years of age, in the second trimester of a normal pregnancy with a single fetus, resident in the political ward in which the CPG was being established and registered at the health facility. Pregnant women were ineligible to participate if they had a pregnancy with complications, such as vaginal bleeding, premature contractions or if clinical assessment suggested that they may require more specialized care. Pregnant women ineligible due to medical exclusion were immediately referred to an appropriate level of care by study clinicians based on existing State Ministry of Health (SMOH) referral protocols. Ethical approval was granted by FHI 360’s Review Board, U.S.A and the National Health Research Ethics Committee (NHREC), Nigeria. CPG facilitators and staff responsible for running ANCs obtained the informed consent of all pregnant women who opted and were eligible to participate in the study. Following this, a questionnaire to capture sociodemographic data was administered to each pregnant woman at enrollment in their local language (Hausa). Antenatal and postnatal client visit information and clinical updates were documented on antenatal and postnatal cards which were held by the study participants, and on antenatal registers which were kept at the health facility. Data from these records were captured electronically on Open Data Kit (ODK) platform installed on android smart phones at each site and stored centrally in a secure server. Data were summarized with frequencies and percentages; the quantitative numeric variables such as age, number of deliveries, number of previous pregnancies and number of deliveries were transformed to categorical variables. Given the low utilization of healthcare services in northern Nigeria, we developed a composite variable called “critical uptake of healthcare”, defined as attending ANC in the 3rd trimester and early postnatal care session (within 2 weeks after delivery) or immunization at birth. Chi-square tests were conducted to compare the differences between the intervention and the control groups with respect to each background characteristic and intervention outcome indicator. Bivariate logistic regression analyses were used to test associations between CP and uptake of services for mother-baby pairs in care. Variables significant at p < 0.2 were considered for inclusion in multivariate Log-binomial regression models. The models were controlled for age, number of previous pregnancies and number of deliveries, respondent’s occupation and partner’s occupation. The educational status of pregnant women participating in the study was not controlled for in the multivariable model because information was not collected on this variable. However, the study was carried out in rural communities where married women had limited access to formal education beyond primary school level. Statistical analysis was done using STATA 12 software.
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