Five Ways an Innovative Program Increased Facility Birth in Nigeria

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By: Nnenna Ihebuzor, Director of Primary Health Care Systems Development; Seye Abimbola, Research Fellow; Ugo Okoli, Program Director of SURE-P Maternal and Child Health Programme, Nigeria's National Primary Health Care Development Agency

This post is part of our Translating Research into Practice Series, which features guest posts from authors of the MHTF-PLoS open-access collections describing the impact of their research since publication.

The Midwives Service Scheme (MSS) was set up as a game changer to reduce maternal and child mortality so Nigeria could achieve the Millennium Development Goals (MDGs) on maternal and child health (MCH). Established by the national government in 2009 to improve the availability of skilled birth attendants in rural communities, the program engages newly graduated, unemployed and retired midwives to work temporarily in rural areas. Four midwives are posted for one year to selected primary health care (PHC) facilities to provide the human resources for health necessary to achieve the MDGs in their states and local government areas.

1. Scale up

Since the publication of our PLoS Medicine paper, the MSS has subsequently been scaled up from 625 PHC facilities to an additional 375 facilities, providing 1,000 facilities across Nigeria with an additional 4,000 midwives and 1,000 community health extension workers.

2. Antenatal care, facility delivery, and family planning increase, maternal and neonatal mortality decrease

The MSS continues to contribute to improved health outcomes in the rural communities where antenatal care visits and facility delivery have increased by more than 100%, family planning uptake by more than 200% and maternal and neonatal mortality have decreased by 19% and 5%, respectively, since the 2009 baseline. In 2012, inspired by the success of the MSS, the national government created an MCH component of the Subsidy Reinvestment and Empowerment Programme (SURE-P), which provides an additional 1,000 PHC facilities and strategies to mitigate some challenges encountered in implementing the MSS. Since its commencement, routine monitoring data show a 50% reduction in maternal mortality, 48% increase in antenatal visits, 61% increase in skilled birth attendance and 59% increase in first time acceptors of contraceptives in SURE-P MCH facilities compared to the baseline data.

3. Policy Change for Family Planning

The experience of implementing the MSS has helped reveal to the national government the existing realities of PHC in Nigeria. This has contributed to influencing a change in national policy to now allow community health extension workers, who form the bulk of the PHC workforce in Northern Nigeria, to provide contraceptive injectables to women.

4. Conditional Cash Transfers Increase Facility Delivery

Since antenatal care uptake far outpaces facility deliveries within the MSS, SURE-P MCH includes a conditional cash transfer component that is currently being piloted in 18 of Nigeria’s 36 states. Pregnant women receiving the cash transfer are required to attend four antenatal care visits, deliver in a facility and attend postnatal visits. In return, they are given N5,000 (US$32), pro-rated based on the number of conditions they meet. Preliminary results show a 27% increase in facility delivery with this incentive.

5. Improved community engagement and human resources investment

Further, the MSS has renewed attention to community engagement in PHC by reactivating community health committees, which have been successful in ensuring community ownership and support for health workers. To support these committees in generating demand for MCH services, SURE P MCH introduced a cadre of 6,000 lay community-based health workers nationwide. Selected by the committees, they help pregnant women, mothers and their children use PHC facilities along the continuum of care.

Despite these improvements, the high health worker attrition within the MSS continues. This is worse in northern Nigeria, where in some states only one third of deployed midwives stay. SURE-P MCH is trying to address the challenges responsible for attrition: challenging living and working conditions, irregular payment of salary and deployment far from home, since the majority of the midwives are from southern Nigeria.

The way forward

Although we’ve seen great success from the MSS, SURE-P MCH and the MSS together support only 10% of PHC facilities in Nigeria. While they significantly improve health outcomes where they are implemented, nothing short of active support for PHC by states and local governments will make a major dent on national MCH indices to affect progress towards the MDGs. Translating MSS into significant improvements in national MCH indices requires innovative ways of getting sub-national governments to support PHC. One such way is contained in the 2014 National Health Bill, which was signed into law by President Goodluck Jonathan on December 9th, 2014. The bill guarantees that 1% of national revenue will go to PHC, but sub-national governments have to match federal allocation as a condition for accessing support for PHC. Hopefully this new law will help us to turn the page on PHC governance in Nigeria.