Reducing maternal and newborn mortality in Nigeria—a qualitative study of stakeholders’ perceptions about the performance of community health workers and the introduction of community midwifery at primary healthcare level

Abstract

BackgroundRural communities in Nigeria account for high maternal and newborn mortality rates in the country. Thus, there is a need for innovative models of service delivery, possibly with greater community engagement. Introducing and strengthening community midwifery practice within the Nigerian primary healthcare system is a clear policy option. The potential of community midwifery to increase the availability of skilled care during pregnancy, at birth and within postpartum periods in the health systems of developing countries has not been fully explored. This study was designed to assess stakeholders’ perceptions about the performance of community health workers and the feasibility of introducing and using community midwifery to address the high maternal and newborn mortality within the Nigerian healthcare system.MethodsThis study was undertaken in two human resources for health (HRH) project focal states (Bauchi and Cross River States) in Nigeria, utilizing a qualitative research design. Interviews were conducted with 44 purposively selected key informants. Key informants were selected based on their knowledge and experience working with different cadres of frontline health workers at primary healthcare level. The qualitative data were audio-recorded, transcribed and then thematically analysed.ResultsSome study participants felt that introducing community midwifery will increase access to maternal and newborn healthcare services, especially in rural communities. Others felt that applying community midwifery at the primary healthcare level may lead to duplication of duties among the health worker cadres, possibly creating disharmony. Some key informants suggested that there should be concerted efforts to train and retrain the existing cadres of community health workers via the effective implementation of the task shifting policy in Nigeria, in addition to possibly revising the existing training curricula, instead of introducing community midwifery.ConclusionApplying community midwifery within the Nigerian healthcare system has the potential to increase the availability of skilled care during pregnancy, at birth and within postpartum periods, especially in rural communities. However, there needs to be broader stakeholder engagement, more awareness creation and the careful consideration of modalities for introducing and strengthening community midwifery training and practice within the Nigerian health system as well as within the health systems of other developing countries.

Working towards universal health coverage: a qualitative study to identify strategies for improving student enrolment for the pre-service training of nurses, midwives and community health workers in Nigerian health training institutions

“…According to National Guidelines for primary healthcare systems in Nigeria, junior community health extension workers (JCHEWs) should promote the community’s participation in health-related activities, conduct home visits, undertake clients’ follow-up as well as identify and then register pregnant women for antenatal care (ANC). The JCHEWs should spend about 90% of their time working within communities but in addition they should provide some health facility-related services [ 8 , 9 ]. JCHEWs are trained for about 2½ years on the same skills as community health extension workers (CHEWs), but the secondary school certificate scores required for admission for JCHEW training are lower than the scores required for entry into CHEW training [ 6 ].…”

“…CHEWs train for 3 years to provide basic health services in primary healthcare facilities and within communities [ 6 ]. CHEWs should spend less time (~ 40% of their time) working within communities and more time working in health facilities, managing patients and attending to clients according to clinical protocols [ 9 ]. Both CHEWs and JCHEWs do not receive competency-based midwifery training during their pre-service training in Colleges of Health Technology [ 6 , 10 ].…”

“…Both CHEWs and JCHEWs do not receive competency-based midwifery training during their pre-service training in Colleges of Health Technology [ 6 , 10 ]. Lastly, community health officers (CHOs) have more managerial responsibilities in health facilities, but also carry out similar community-based and facility-based tasks as the CHEWs [ 9 ].…”

“…Within the HRH project, frontline health workers refer to nurses, midwives and community health workers, i.e. community health extension workers, junior community health extension workers and community health officers [ 9 ]. The HRH project collaborated with the Nursing and Midwifery Council of Nigerian (NMCN), which is the regulatory institution for nurses and midwives in the country as well as the Community Health Practitioners’ Registration Board of Nigeria (CHPRBN) which is the regulatory institution for community health workers in Nigeria [ 9 , 20 , 21 ].…”

“…community health extension workers, junior community health extension workers and community health officers [ 9 ]. The HRH project collaborated with the Nursing and Midwifery Council of Nigerian (NMCN), which is the regulatory institution for nurses and midwives in the country as well as the Community Health Practitioners’ Registration Board of Nigeria (CHPRBN) which is the regulatory institution for community health workers in Nigeria [ 9 , 20 , 21 ]. The NMCN and CHPRBN, as regulatory institutions typically liaise with health training institutions during the development and upgrade of training curricula, during the student enrolment process as well as to ensure the enforcement of standards for graduation, indexing and licensure of these key cadres of healthcare workers, i.e.…”