Abstract
The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support structures. Innovative communication body tools and the rote learning Rapid Imitation Practice training methodology enabled low-literate volunteers to saturate their communities with informed group discussions transferring communication capacity and ownership to the discussion participants. CCER is especially efficient because virtually every timely, community referral for emergency maternal care results in a saved life, whereas on average, only one in every eight births delivered by an SBA (12%) is expected to be a delivery-associated complication requiring lifesaving care.
Acknowledgments
Most of the data reported in this study were collected as part of the PRRINN-MNCH project activities and are published on the PRRINN-MNCH website (www.prrinnmnch.org). The authors acknowledge the support of the government, community leaders and members, staff, consultants, and senior technical advisors who participated in a number of surveys, assessments, and discussions and led the design of some of the interventions reported here. We also acknowledge the support of Dr Rodion Kraus, Deputy National Program Manager and the entire PRRINN-MNCH team.
The views expressed in this paper are those of the authors and do not represent the views of their previous or current institutions or organizations.
Author contributions
All the authors provided substantial contribution to the conception and design, acquisition of data, analysis and interpretation, revision of drafts, and gave their final approval for the final version of the manuscript.
Disclosure
The authors report no conflicts of interest in this work.