Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy

Figures & data

Table 1 Comparison of key reproductive health outcomes, baseline 2009 to end line 2013, PRRINN-MNCH States of Katsina, Yobe, and Zamfara

Key maternal health indicators	BHS	EHS	EHS control	EHS intervention	BHS versus EHS	Intervention versus control
Maternal mortality ratio/100,000 live birthsa	>1,271	1,190	1,262	1,057	NA	NA
Births attended by an SBA (%)	11.2	23.9	23.6	26.8	<0.001	0.012
Women receiving ANC by a trained person (%)	24.9	48.8	44.6	53.0	<0.001	<0.001
Women who know four maternal danger signs (%)	10.2	21.7	14.0	29.4	<0.001	<0.001

Notes: Adapted from PRRINN-MNCH.⁴⁰

a Includes data from Jigawa State. Chi-square test is used for all the comparisons.

Abbreviations: ANC, antenatal care; BHS, baseline household survey; EHS, end line household survey; NA, not applicable; PRRINN-MNCH, Partnership for Reviving Routine Immunization in Northern Nigeria, Maternal Newborn and Child Health; SBA, skilled birth attendant.

Table 2 Calculation of the average cost per community supporting Community Communication Emergency Referrals, PRRINN-MNCH, July 2012

State	Maternal deaths averted through CCERs	Number of CCER communities	CCER investments at an average cost of N85,037.00 (£340) per community	Cost per life saved in UK £s (2012)
	a	b	c = b × £340	d = c/a
Katsina	988	30	£10,200	£10
Zamfara	845	45	£15,300	£18
Yobe	822	31	£10,540	£13
Total	2,655

Note: Calculation in the table adapted from Shutt.¹⁸

Abbreviations: CCER, Community Communication Emergency Referrals; PRRIN-MNCH, Partnership for Reviving Routine Immunization in Northern Nigeria, Maternal Newborn and Child Health.

Table 3 Calculating the TC faced by women throughout the maternal state as a percent of TB

Category	Symbol	Formula
Direct causes	DCa	15% of TB
Direct causes	DCa	70% of TC
Direct causes	DC	15% of TB =70% of TC
Total complications	TC	15% of TB/70%
Total complications	TC	15%/70% of TB
Total complications	TC	21% of TB

Note:

a Data from WHO.¹⁹

Abbreviations: DC, direct cause; TB, total births; TC, total complications.

Table 4 Calculation of the estimated percent of the TC that are delivery-associated complications occurring during the period mothers are expected to be under the care of an SBA (DAC)

Category	Symbol	Formula (%)	Distribution of timing of maternal mortality (%)
Death during pregnancy	DPa	24	24
Death during delivery	DDa	16	16
Death during postpartum	DPPa	60	60
Death from pregnancy through postpartum	DP – DPPa	100	100
Complications during first week postpartum	CWPPb	66 × DPP	40
Percent of delivery-associated complications	DAC	DD + CWPP	56

Notes:

a See de Bernis et al²⁰;

b See Nour.²¹

Abbreviations: DAC, delivery-associated complications; DC, direct cause; DD, complications expected to occur during delivery; DP, death during pregnancy; DPP, death during postpartum; DP – DPP, death from pregnancy through postpartum; CWPP, complications expected to occur during the first week postpartum; SBA, skilled birth attendant; TC, total complications.

Table 5 Calculation of the estimated percent of DACB along with expected PRRINN-MNCH delivery-associated complications

Category as a percent	Symbol	Formula	PRRINN-MNCH SBA deliveries
Total births	TB		297,349
Total complications as a percent of total births	TCa	21% of TB	62,443
Delivery-associated complications as a percent of total complications	DACb	56% of TC	34,968
Delivery-associated complications as a percent of total births	DACB	56% of 21% =11.76% 12% of TB	34,968

Notes:

a Caculated as 15% of TB/70% (similar to calculations presented in Table 3);

b Calculated as deaths during delivery + complications during first week postpartum (similar to calculations presented in Table 4).

Abbreviations: DAC, delivery-associated complications; DACB, total births with delivery-associated complications; PRRINN-MNCH, Partnership for Reviving Routine Immunization in Northern Nigeria, Maternal Newborn and Child Health; SBA, skilled birth attendant; TB, total births; TC, total complications.

Figure 1 Comparison of estimated lives saved by the SBA delivery strategy and lives saved by CCER strategy over 4 years in the PRRINN-MNCH intervention sites.

Abbreviations: CCER, Community Communication Emergency Referrals; PRRINN-MNCH, Partnership for Reviving Routine Immunization in Northern Nigeria, Maternal Newborn and Child Health; SBA, skilled birth attendant.

Table 6 Key maternal, newborn, and child knowledge among respondents at baseline and end line, PRRINN-MNCH Knowledge, Attitude, and Practices Survey

Key MNCH information	Baseline November 2009 (%)	End line February/March 2011 (%)
Four maternal danger signs	26	91
Three benefits of ANC	19	69
Timely breast-feeding initiation	28	72
Routine immunization schedule	15	60
Knows CHVs working on EMC	5	84
Awareness of community EMC fund	1	83
Awareness of ETS drivers	1	81
Awareness of community blood donors	1	82

Note: For details of the Knowledge, Attitude, and Practices Survey, see PRRINN-MNCH.²⁹

Abbreviations: ANC, antenatal care; CHVs, community health volunteers; EMC, an earlier term for Community Communication Emergency Referral; ETS, emergency transport scheme; PRRINN-MNCH, Partnership for Reviving Routine Immunization in Northern Nigeria, Maternal Newborn and Child Health.

Table 7 Self-reported behavior change – plans made for a maternal emergency (%)

Plan made	Katsina		Yobe		Zamfara
	Baseline	End line	Baseline	End line	Baseline	End line
Saved money	68.0	100.0	92.5	80.1	85.5	78.1
Knew maternal danger signs	24.1	100.0	29.5	59.6	2.6	40.6
Identified an emergency driver	13.2	83.9	3.4	25.6	1.3	7.9
Identified a woman helper to call for help in an emergency	8.9	78.9	17.1	23.5	5.3	17.7
Obtained standing permission from husband to be rushed to the hospital	7.6	75.2	46.6	26.4	15.8	22.4
Identified blood donors to accompany woman to hospital	7.3	18.8	6.2	22.7	0.0	5.3
Family member knows about maternal emergency savings scheme	6.3	76.1	7.5	28.9	0.0	9.8
Respondents who planned at least four of the above	4.1	96.8	11.6	27.5	0.0	23.5

Notes: Data from PRRINN-MNCH.¹⁷ Baseline KAP study focused on cluster 2 communities and 2013 end line KAP survey focused on clusters 1, 2, and 3 (by which time program support to cluster 1 communities was limited to monthly data gathering). Data from communities with less than 1 year of implementation were excluded. Differences between the baseline and end line for each state and each of the plans are statistically significant (P<0.001).

Abbreviation: KAP, Knowledge, Attitude, and Practice Survey.

Figure 2 The lifesaving chain of events established by CCER.

Abbreviations: CCER, Community Communication Emergency Referral; CV, community volunteer; EMC, an earlier term for Community Communication Emergency Referral; ETS, emergency transport scheme.

Figure 3 Case study 11, Latifa, aged 18 years.

Abbreviation: CV, community volunteer.

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