https://orcid.org/0000-0002-1691-9682
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Abstract
The slow pace of improvement in service delivery and health outcomes for pregnant women and newborns in developing countries has been a major concern for policy makers in recent decades. This paper presents the results from a randomized controlled trial of a community health worker program designed to enhance uptake of child and maternal health services in Northern Nigeria. Three interventions were evaluated: the deployment of community health educators, health educators with the provision of safe birth kits, and health educators with community dramas. The results suggest that the interventions increased utilization of antenatal, postnatal, and infant care. Maternal and newborn health practices improved as well as health knowledge. In addition, the community health worker program was more effective when supplemented with additional program components.
Notes
Acknowledgements
We would like to thank the Macarthur Foundation and USAID - Traction for funding, and particularly thank Judith Helzner, Erin Sines, Kole Shettima, and Oladayo Olaide at Macarthur for their ongoing leadership in the project. We would also like to extend our thanks to the Planned Parenthood Federation of Nigeria for collaborating on this evaluation, most particularly Ibrahim M. Ibrahim, Okai Haruna, John Adegbite, Damilola Toki, and Nafisatu Adamu. A large number of individuals contributed to the success of our field work, above all Laura Costica and Fatima Abdulaziz, without whose efforts the project would not have been possible; we would also like to acknowledge (in chronological order) Damilola Owolabi, Comfort Boman, Habiba Makanjuola, Salamatu Chiroma, Asinga Joshua Ungbo, Tsuya Halilu, Megan Kearns, Ahmed Sarki, Abdullahi Bulama, and Kelvin Chukwuemeka. We would also like to thank Jamin Dora Duba, Emmanuel Attah, and Kolapo Usman at the National Population Commission for their invaluable assistance, and the Ministry of Health of Jigawa state and particularly the Operational Research Committee (ORAC) chaired by Dr. Mohammad Abdullah Kainuwa for their guidance and leadership. For assistance in data analysis, we thank Luca Fachinello, Priya Iyer, and above all, Laura Costica. Data and code are available upon request.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes
1 In practice, MSS-served facilities were in fact characterized by frequent stockouts (Okeke et al., Citation2016).
2 Founded more than 25 years ago, PPFN is now one of the oldest indigenous organizations in Nigeria offering sexual and reproductive health services; however, the interventions proposed as part of this evaluation were new to the organization.
3 The kits were identical to those available to midwives working in the MSS primary health care centers.
4 Chari and Okeke (Citation2014) conclude that a policy-induced shock to the supply of institutional deliveries did not have a significant effect in reducing newborn mortality in Rwanda. Evidence from Malawi suggests a government ban on the use of traditional birth attendants did result in a significant increase in utilization of formal sector care, but no overall decline in newborn deaths (Godlonton & Okeke, Citation2016).
5 Power calculations are conducted following Hayes and Bennett (Citation1999). This is assuming a baseline maternal morbidity rate of 35 per cent, and a baseline infant mortality rate of 47 deaths per 1000 births. In addition, the design assumed a birth rate of 46 per 1000 population and accordingly 21 sampled births observed per year per community of 3000 individuals given that 15 per cent of households are sampled. The coefficient of variation between clusters k was assumed to be.2.
6 The trial was registered with the American Economic Association registry (Leight, Nyqvist, & Sharma, Citation2016), and registered at clinicaltrials.gov. The protocol number is NCT01487707.
7 All respondents provided informed written consent, and all data were collected by electronically by trained same-sex enumerators using ODK software.
8 In the event an enumerator became aware of a birth more than three days after the birth, she was still instructed to conduct the three-day survey as soon as possible, and then return for the 28-day survey. In the event she became aware of a birth more than 28 days after birth, she was instructed to conduct the survey up to three months after birth.
9 Some additional intensive data collection targeted to minimize attrition continued until October Citation2016.
10 No systematic data was collected on miscarriages, other than one question posed at the endline as to whether the respondent experienced at least one miscarriage in the preceding two years.
11 More evidence around the hypothesis that there is no selection into the subsample of women reporting births can be found in Section S6 in the Supplementary Material.
12 The control variables employed include all those reported in the balance tests in Panel A of Table S3: a dummy variable for whether the respondent is married, the number of co-wives, age at marriage, the number of marriages reported, age, a dummy for whether the respondent has ever attended school, a dummy variable for whether the respondent reads Hausa, a dummy variable for Muslim, current birth parity, and a wealth index. We also include dummy variables equal to one if the respondent is observed in the 3-day and 28-day surveys, and in the audit survey.
13 There is no evidence that spillovers are higher in control communities that are geographically more proximate to treatment communities.
14 The antenatal care index is equal to the mean of indicator variables for receiving important components of antenatal care: utilizing care in the first trimester, receiving more than half of available ANC services, receiving iron folic pills and the tetanus vaccine, and receiving advice on danger signs during pregnancy. The observed intervention effect is largely driven by increases in the receipt of iron pills and tetanus vaccines, as well as reported counseling about pregnancy danger signs.
15 In practice, facility delivery and skilled attendance at birth are almost equivalent, given that health personnel generally do not attend home births in this region.
16 Given that the effect is observed in all three treatment arms, it is plausible to hypothesize that it primarily reflects the effects of the CORPs, rather than the ancillary interventions.
17 It should be noted that the sample for neonatal morbidity is restricted, given that this information was reported only in the 28-day survey. We also collected limited data on miscarriages at endline, and find no significant effect of the interventions on the rate of miscarriage, defined as the loss of a pregnancy in the first two trimesters. Data on induced abortions were not collected, but this could be another potential channel for selection in the sample of households reporting a birth.
18 Endline anthropometric data is missing for children corresponding to births observed only in ongoing surveys (133 observations), as well as for an additional 650 observations; for the latter subsample, the adult respondent was surveyed in the endline, but the enumerator assigned to follow-up with a separate anthropometric survey did not locate the household, the respondent declined to provide consent for measurement, or the child was not available.
19 It is important to emphasize that the results should be interpreted cautiously given that the children observed in the anthropometric data are drawn from a subsample of respondents. However, we present evidence in Section S6 that respondents observed only in the endline and those observed in ongoing surveys are not characterized by significant differences in observable characteristics, and thus we cannot reject the hypothesis that the respondents observed in the anthropometric data constitute a random subsample.
20 All the indices are coded such that a higher value indicates more knowledge or more positive attitudes.
21 In the first stage, the coefficient on the treated dummy is.101, significant at the 1 per cent level.
22 Estimating the treatment on the treated specifications for the outcomes reported in Table S5 shows null effects. Limited power is available to estimate treatment on the treated for the anthropometric variables given the reduced sample.