It is now well known that more women die during childbirth in Nigeria as compared to other parts of the world. It’s also a known fact that women who die from pregnancy complications in Nigeria tend to be poor, illiterate women, who reside in rural areas. The major reason that women in rural communities are at higher risk of dying during childbirth is because of lack of health facilities – as such women in rural communities tend not to receive antenatal and delivery care in health facilities. By contrast, they tend to receive antenatal and delivery care either in their homes or in the homes of unskilled traditional birth attendants (TBAs). This means that when they experience complications such as bleeding or hypertension during pregnancy or childbirth, they will not be appropriately managed increasing their risks of death from such complications. The Federal Ministry of Health and the Nigerian Government recommends the use of Primary Health Centres (PHCs) as the entry points to the formal health care system. PHCs are present in almost all Local Government Areas of Nigeria and would be the ideal place for women to seek antenatal and delivery care when they are pregnant. PHCs can manage routine antenatal and delivery care, and they can make early recognition of more severe complications that they would refer to General Hospitals and Teaching Hospitals for more sophisticated care. If this format is followed i.e. all pregnant women in rural communities attend PHCs for routine antenatal and delivery care, the likelihood that women would die from pregnancy complications will be reduced.
In November 2015, the Women’s Health and Action Research Centre (WHARC), one of Nigeria’s leading NGOs, received a grant from the International Development Research Centre (IDRC) of Canada as part of the implementation of IMCHA (Improving Maternal and Child Health in Africa). The objectives of the grant were two-fold;
1) To explore the reasons that pregnant women in rural Nigeria do not use PHCs for skilled pregnancy care; and
2) To identify appropriate interventions for increasing women’s use of skilled pregnancy care offered in PHCs.
We began by conducting a needs assessment study in 20 communities in Esan South East and Etsako East, two predominantly Local Government Areas (LGAs) of Edo State in South-South Nigeria. The results of the needs assessment consisting of a household survey of women in the two LGAs, showed that only 52.6% of pregnant women had received antenatal care and 31.8% delivery care in the community PHCs in the immediate deliveries preceding the survey. Some of the barriers and challenges that prevented women from using PHCs included difficulties with transportation, perceptions relating to poor quality services at PHCs, high cost of services, and lack of knowledge about the use of PHCs for pregnancy and delivery care.
To rectify the situation, we worked with community leaders, 4 PHCs, health providers, LGA officials, the Edo State PHC Develop Agency, and the Federal Ministry of Health in collaboration with the West African Health Organization (WAHO) and the University of Ottawa, Canada to develop a series of interventions that address the barriers and enhance women’s use of PHCs. We designed the interventions to be community-led, and community-driven to ensure its wide coverage and sustainability over time. The interventions included the constitution of Ward Development Committees (WDAs) with members identified by the Kings (Onogies) in the communities, the training of WDAs members to provide house-to-house information on the need for skilled pregnancy care and delivery in PHCs, renovation and provision of basic materials in the PHCs, the re-training of staff, advocacy activities to government officials for increased staffing and funding of the PHCs, community health insurance, the provision of drug revolving funds, and the development of a smart-phone texting device (Text4Life) linked to registered Taxi Drivers that rapidly brought women experiencing pregnancy complications to PHCs.
WHARC recently undertook another house-hold survey of women to determine how this composite (multi-faceted) intervention has helped in improving women’s use of skilled pregnancy care.
The results showed that 74% of pregnant women now use PHCs in the communities as compared to 52.6 % at baseline (an increase of 21.4%). Also, the proportion of women reporting that they used PHCs for delivery in the end-survey was 59%, compared to 31.8% at the beginning (an increase of 27.2%, while the use of postnatal care in PHCs increased from 59.7% to 78.6% (an increase of 18.9%). Also, immunization of children increased from 59.7% to 78.6% after the intervention (an increase of 18.9%). All the increases persisted after multivariable logistic regression analysis was carried out to account for all confounding variables.
These results show that an intervention designed to correct the factors identified by women and stakeholders as responsible for non-use of PHCs can be effective in improving the use of PHCs for skilled pregnancy care by women in rural communities. Some of the factors that accounted for the success of this intervention include
1) The fact that the barriers were identified at the onset through a needs assessment research and inquiry conducted with community stakeholders.
2) The engagement of community stakeholders in the conduct of the research and development of the interventions.
3) The fact that the interventions were led and driven by community stakeholders, especially members of the WDC.
4) The involvement of policymakers, PHC officials and government officials.
We believe that this approach will be useful in scaling up the use and adoption of PHCs for skilled pregnancy care, especially in rural and sub-urban parts of the country.
The links to the publications and narratives relating to the project are provided below for your reading and viewing pleasure.
- Okonofua FE, Ntoimo L, Ogungbangbe J, Anjorin S, Imongan W, Yaya S. Predictors of Women’s Utilization of Primary Health Care for Skilled Pregnancy Care in Rural Nigeria. BMC Pregnancy Childbirth 2018 BMC Pregnancy Childbirth 2018 April 18; 18(1). https://doi.org/10.1186/s12884-018-1730-4
- Okonufua, FE., Ntoimo LFC., Yaya, S., Ogungbangbe J., Imongan W., Ermel J., (2018). Assessing community-led interventions for creating demand for skilled pregnancy care in rural Nigeria: Short-term results from a quasi-experimental research design. https://www.researchgate.net/publication/330521287_Assessing_community-led_interventions_for_creating_demand_for_skilled_pregnancy_care_in_rural_Nigeria_Short-term_results_from_a_quasi-experimental_research_design
- Ntoimo L, Okonofua FE, Igboin B, Ekwo C, Imongan W, Yaya S. Why rural Women do not use Primary Health Centres for Pregnancy Care: Evidence from a qualitative study in Nigeria. BMC Pregnancy and Childbirth 2019 (August), 19: 277. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2433-1
- Yaya Sanni, Okonofua Friday, Ntoimo Lorretta, Idenigwe O, Bishwajit G. Men’s perceptions of barriers to women’s use and access to skilled pregnancy care in rural Nigeria: a qualitative study. Reproductive Health 2019; 16: 86. https://doi.org/10.1186/s12978-019-0752-3.
- Fantaye, A. W., Okonofua, F., Ntoimo, L., & Yaya, S. (2019). A qualitative study of community elders’ perceptions about the underutilization of formal maternal care and maternal death in rural Nigeria. Reproductive Health, 16(1), 164. https://doi.org/10.1186/s12978-019-0831-5
- Chigozie Jesse Uneke, Issiaka Sombie, Henry Uro-Chukwu, Ermel Johnson, Friday Okonofua. Using equitable impact sensitive tool (EQUIST) and knowledge translation to promote evidence to policy link in maternal and child health: a report of the first EQUIST training workshop in Nigeria. Pan African Medical Journal 2017; 28:37. doi:10.11604/pamj.2017.28.37.13289. https://www.panafrican-med-journal.com/content/article/28/37/full/
- Yaya S. Okonofua FE, Ntoimo LF, Udenige O, Bishwajit G. Gender Inequality as Barrier to Women’s Access to Skilled Pregnancy care in Rural Nigeria: A Qualitative Study. International Journal, April 27, 2019. https://pubmed.ncbi.nlm.nih.gov/31028382/
Royal Highnesses and WDC Testimonials on the use of PHC for skilled pregnancy care in rural Nigeria
Women and Healthcare attendance testimonials on the use of PHC for skilled pregnancy care in rural Nigeria
WHARC – leading the pathway to improving the health and social wellbeing of women.