This post is part of a blog series on Malaria in Pregnancy. To view the entire series, click here.
By 2015, the Government of Nigeria aims for 80% of women to receive intermittent preventive treatment of malaria during pregnancy (IPTp). However, according to the 2008 National Demographics and Health Survey, the current rate is only 6.5%.
How can progress towards this goal be accelerated? There are, of course, many reasons for women not receiving IPTp, including significant supply barriers to having sufficient supplies of sulfadoxine-pyrimethamine (SP) in country, but here we would like to focus on another reason – utilization of antenatal care (ANC). In Nigeria, ANC is a key delivery point for IPTp. If women aren’t seeking ANC, they are less likely to receive IPTp. Therefore, a major and persistent barrier to reaching pregnant women with malaria prophylaxis in Nigeria is antenatal care utilization.
While Nigerian policy is that SP be given free of charge through ANC services at public health facilities and non-governmental organizations, women need to physically go to facilities to access this free treatment. According to the MICS 2007, women in rural areas are less likely to uptake IPTp than women in urban areas. This may be because most services provided by private and public providers are clinic-based, with minimal outreach, home, or community-based services (NSHDP).
According to a report by the DFiD-supported PRRINN-MNCH Project (Demand/PRRINN), many women either do not know what antenatal care is, or confuse it with seeking curative care while pregnant. “Changing such health seeking behavior will not be easy, and will require an emphasis on creating demand as well as improvements in the supply of services.”
In the context of northeast Nigeria, there is a significant mismatch between where maternal and newborn health problems happen (largely the home), how those who have the problems (mothers, newborns) are reached (through gatekeepers) and where help might be currently available (facilities). Alternative methods of getting information and services into the home are urgently needed if health is to be improved. The Bill & Melinda Gates Foundation worked with PSI and Society for Family Health to find new ways to meet with women in their homes in Gombe State, with the aim to increase utilization of available services and interventions to improve maternal and newborn health outcomes. This project specifically tapped two unique resources – traditional birth attendants (TBAs), and female community volunteers from the Federation of Muslim Women’s Associations in Nigeria (FOMWAN).
Throughout the project TBAs and FOMWAN volunteers identified pregnant women by going house to house, through information from their neighbors or members of the family, at religious gatherings and ceremonies, and through observation of pregnancy signs. At the beginning of the project, only 17.5 % of women in Gombe state received services from health facilities, despite free ANC throughout the state. As a result of the project, from March 2010-October 2011, IPTp use increased from 51.61% to 55.8% in the study area. In particular, FOMWAN volunteers made a significant impact, with a 9.2% increase in ANC utilization and a 20% increase in anti-malarial receipt in FOMWAN study areas. Continued improvement is expected over the life of the project, which will continue for four years. Clearly, there is potential here to utilize these frontline workers that are already an entrenched part of community to form a bridge between women in their homes, and facility-based care.
As we move forward, in Nigeria and elsewhere, we will need to work together as a global community to find innovative ways to break down barriers to reaching pregnant women with malaria prevention, diagnosis, and/or treatment. Could this type of engagement with community-based workers be one such way?