Despite Nigeria’s growing economy and significant cadre of well-trained health providers, Nigerian mothers and their newborns continue to die during and directly after childbirth at an alarming rate. Nigeria, the most populated country in Africa, is also home the highest annual number of infants newly infected by HIV in the world. Of the estimated 6,356,730 total births in 2012, almost 60,000, or 10 percent of babies, became infected with HIV, most of them through their mothers.
To reverse these disturbing trends, coverage, and especially quality, of health services for mothers and their children need to be enhanced. With wide variation in health indicators across different states and localities, new resources must be invested in underserved areas where maternal and child health, family planning, and HIV services have not been fully integrated into the primary health care system.
The national government has pledged, through enabling policies and commitment to international health goals, to support high-impact interventions that will save the lives of many more mothers and newborns, but financial obligations to date have not fully supported the realization of those commitments. National commitments must be matched by the support of all local and state governments to truly achieve a more positive outlook for Nigerian families, irrespective of where they live.
With funding from USAID/Nigeria, E2A is tackling myriad systemic obstacles to improve the health of Nigerians through two programs—one focused on integrated prevention of mother-to-child transmission of HIV (PMTCT) services and another on life-saving maternal and newborn health services. E2A is also conducting an operations research study in Cross River and Kaduna states to determine if community health extension workers can safely provide implants. The evidence generated could support a policy shift that would allow community health extension workers to provide implants to their clients, thereby increasing access to long-acting family planning among a wider swath of the population.
Private-Sector PMTCT Plus Project
Evidence has shown that when PMTCT and reproductive, maternal, and newborn care services are fully integrated within a country’s primary health care system, demand for, access to, coverage, and use of these services increases. As of 2012, however, only 6 percent of health facilities in Nigeria provided PMTCT services.
E2A’s Nigeria Private-Sector PMTCT Plus project applies a rights-based approach to address issues that have prevented the widespread provision of integrated PMTCT services and have adversely affected a woman’s ability—despite her desire—to prevent HIV transmission to her baby. They include women’s lack of economic power, stigma around HIV, and social beliefs and norms.
E2A is working in Akwa Ibom, Cross River, Lagos, and Rivers states to provide a standardized package of PMTCT and tuberculosis services that are integrated in quality reproductive, maternal, and newborn care services at private healthcare facilities. These four states were selected based on the many pregnant women living there who need prophylaxis for PMTCT, weak capacity of their governments to monitor private healthcare facilities, the availability of health services, the high number of sites without integrated HIV and AIDS services, and the significant proportion of populations affected by HIV.
PMTCT Plus aims to increase access to and uptake of these high-quality, integrated services and ensure the capacity of the Government of Nigeria to sustainably manage and coordinate HIV and AIDS programs at private facilities by doing the following:
- Improving commodity logistics management.
- Increasing demand for the integrated services.
- Improving identification, follow up, and retention of HIV-positive persons and HIV-exposed infants at all levels of service provision.
- Improving capacity of health care facilities and providers to provide quality, integrated services.
- Improving each state and locality’s coordination and oversight capacity to manage the integrated health program.
PMTCT Plus places a special focus on youth-friendly services, given that 35 percent of young people have an unmet need for family planning, less than half of women younger than 20 receive antenatal care, and only 25 percent of these young mothers deliver in a health facility. PMTCT Plus also strengthens referral systems to achieve stronger partnerships between the private and public sector, and supports community-based organizations and professional associations to promote information sharing that reduces missed opportunities, and encourages better follow-up for postnatal care after hospital discharge.
Saving Mothers, Giving Life
In Cross River State, E2A, in partnership with the Saving Mothers, Giving Life initiative, will replicate an evidence-based, comprehensive maternal and newborn health intervention that was successfully piloted in Uganda and Zambia and resulted in a 35 percent decline in mothers dying as a result of childbirth at participating facilities. This partnership will leverage and build on PMTCT Plus to deliver high-impact, essential maternal and newborn health services in all public and private facilities providing labor and delivery services in Cross River State.
The Saving Mothers, Giving Life model constitutes a suite of evidence-based interventions to improve the quality and coverage of maternal and newborn health services, which are integrated with HIV services, to address the three delays to women accessing life-saving care:
- decision to seek appropriate care;
- reaching care in a timely manner; and
- receiving quality, respectful care at the facility, with a focus on time of labor, delivery, and the first 48 hours postpartum.
With this initiative and in partnership with relevant stakeholders, E2A aims to achieve a 30 percent reduction in maternal mortality and a 20 percent reduction in newborn mortality by September 30, 2017 at facilities in Cross River State.
Through Saving Mothers, Giving Life, E2A will seek to ensure that every woman has access to clean and safe delivery services, and in the event of an obstetric complication, life-saving emergency care within two hours. The initiative will consist of the following components:
- Improving the quality of maternity care and institutional delivery services, including emergency obstetric and newborn care.
- Ensuring women and their newborns receive key health services in an integrated manner, including counseling on self-care, knowledge of danger signs, and the importance of birth planning; access to HIV counseling, testing, treatment and PMTCT services; prevention and treatment of malaria; treatment of anemia; postabortion care; and postpartum family planning.
- Strengthening community and facility health information systems to capture, evaluate, and report birth outcomes.
- Increasing use of life-saving innovations, such as Manual Vacuum Aspiration, antenatal corticosteroids, chlorhexidine cord care, kangaroo care, and simplified antibiotic regimens for neonatal sepsis.
E2A will work closely with national, state, and local officials to support the institutionalization of supportive policies and standards, adapt training materials, and train national master trainers on use of high-impact interventions. At the community level, E2A will improve referral systems and focus on community outreach to counsel women, families, local leaders, and community organizations on the importance of high-impact interventions, such as four antenatal care visits and birth planning.
This initiative is planned to commence in the first quarter of 2015. An extensive health facility assessment to inform a detailed implementation plan is ongoing in nine Local Government Areas of Southern Cross Rivers state.
Research Study: Community-Based Provision of Implants Via Task Sharing
Less than 10 percent of reproductive-age women use a modern contraceptive method. Use of long-acting methods is particularly rare; in part, due to constrained access to them. Long-acting methods, by national guidelines, can only currently be provided by high-tier medical personnel. Enabling community health extension workers in Nigeria to provide implants would undoubtedly expand access to this highly effective long-acting method, particularly in areas where there is a shortage of medical professionals.
Community health extension workers already spend half their time in the community and half at static health facilities to compensate for these human resource shortages. Evidence from Ethiopia, where health extension workers have been trained to provide implants, suggests that with adequate training community health extension workers in Nigeria can also provide implants at facilities where they currently work. Based on this and other evidence, the World Health Organization recently released recommendations for research that will support task shifting for implants to optimize the delivery of essential reproductive and maternal and newborn health interventions in resource-poor settings.
E2A is therefore undertaking a study in Kaduna and Cross River states to assess the effects of community health extension workers providing implants on family planning uptake and method mix. Specifically, the study will:
- Identify additional training required by community health extension workers in order for them to provide implants.
- Document the process and cost of involving community health extension workers in the provision of implants.
- Examine how the provision of implants by community health extension workers affects family planning uptake and method mix.
- Examine safety issues related to the provision of implants by community health extension workers.
In each study state, selected health facilities (and their catchment areas) are divided into two categories: those in which community health extension workers are trained to provide implants (intervention sites) and those in which community health extension workers are not trained to provide implants (comparison sites).
The study aims to support a government-led policy shift that would expand community health extension workers’ current family planning tasks to include provision of implants; contribute to increased family planning uptake by increasing access to new methods at community level; and sensitize stakeholders and seek support to improve underserved populations’ access to long-acting methods through culturally sensitive approaches. All demonstration activities are documented to guide scale-up.