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Obstetric fistula is a life transforming event resulting in embodied biographical disruption. Survivors suffer myriad long‐term physical and emotional consequences. This paper is an account of a narrative inquiry, conducted with 15 fistula survivors in North‐central, Nigeria, who described how their identities had been transformed by their condition. A narrative therapeutic approach, using Frank's 'chaos, restitution and quest' typology, was used to map their recovery narratives. 'Chaos', described by Frank as the opposite of restitution, dominated, with women losing hope of recovery. Women's shift towards 'restitution' began with treatment, but inadequate health‐care access often delayed this process. In their quest narratives, women's life and identify changes enabled them to derive meaning from their experience of obstetric fistula within the context of their own lives. The findings highlight socio‐structural factors raising the risk of obstetric fistula, which in turn causes biographical disruption and hampers sufferers' treatment and recovery. Rehabilitation should include income‐generating skills to bring succour to survivors, particularly those whose incontinence persists after repairs. [ABSTRACT FROM AUTHOR]

Background: Feminist scholarship is acutely aware that health is not dependent on behavioural choices alone but on interlocking social determinants that affect people's capacity to lead healthy lives. Women are situated within social structures that impact their health. but there is limited engagement with interpretive tools such as feminist theories that centre the realities of African women, particularly in the context of maternal health. It is imperative that women's control over their reproductive health and autonomy in seeking care, particularly skilled maternal healthcare are understood within this context. This study seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Feminist scholarship acknowledges that women are situated within social structures that impact their health. Therefore, this paper seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Method: This is a cross-sectional qualitative study of a total of 64 participants: 39 women and 25 men in Ewato and Okpekpe communities, two Local Government Areas of Edo State in southern Nigeria. The study presents findings from eight sex-and-age desegregated focus group discussions. This study reports on emergent data related to women's decision-making in accessing skilled maternal care. Data were transcribed and translated to English. Using the NVivo 1.6 software, data were coded and analyzed using a conventional approach to content analysis. Results: Findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism's concepts of alliance, community and connectedness were highlighted through men's constructive involvement in maternal health. Furthermore, women were shown to maneuver patriarchal norms to gain control of their healthcare decisions. Conclusion: This study offers a different narrative from the dominant view of non-Western women, specifically African women, as oppressed passive victims who are ineffectual in taking charge of their health. From the perspective of negofeminism, women navigate patriarchal environments to yield the best possible maternal health outcomes. The current study can be useful in informing policy and programming that acknowledges women's social embeddedness. [ABSTRACT FROM AUTHOR]

Background: Access to health services during pregnancy, childbirth and the period after birth provides a substantial opportunity to limit cases of maternal mortality. In sub-Saharan Africa, the proportions of women who utilize health services remain below 70%. This study examined the factors associated with partial and adequate maternal health services utilization in Nigeria. Methods: This paper used data from 2018 Nigeria Demographic and Health Survey (DHS) comprising 21,792 women aged 15–49 years who had given births within five years of the survey. The study focused on antenatal care attendance, place of birth and postnatal care using a combined model. Multinomial logistic regression was applied in the analysis. Results: About 74% of the women attended antenatal care, 41% gave birth in health facilities and 21% attended postnatal care. While 68% of the women partially utilized health services, 11% adequately utilized the services. The odds of partially and adequately utilizing health services increased for ever married women, women with secondary or higher education, from richest households, living in urban area, having no problem either getting permission to visit health facility or reaching health facility. Conclusions: This study has revealed the factors associated with partial and adequate utilization of maternal health services in Nigeria. Such factors include education, household wealth, marital status, employment status, residence, region, media exposure, getting permission to use health service, unwillingness to visit health facility without being accompanied and distance to health facility. Efforts aimed at improving maternal health services utilization should place emphasis on these factors. [ABSTRACT FROM AUTHOR]

Background: Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs. Methods: We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards. Results: The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support. Conclusion: This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required. [ABSTRACT FROM AUTHOR]

Purpose: This paper describes the design of a theory-informed pragmatic intervention for adolescent perinatal depression in primary care in Nigeria. Methods: We conducted Focus Group Discussions (FGDs) among 17 adolescent mothers and 25 maternal health care providers with experience in the receipt and provision of care for perinatal depression. The Consolidated Framework for Implementation Research (CFIR) was used to systematically examine the barriers and facilitators affecting adolescent mothers' use of an existing intervention package for depression. The Theoretical Domain Framework (TDF) and the Capability, Opportunity, Motivation, Behaviour (COM-B) model were used to analyze the results of the data across the five CFIR domains. Results: FGD analysis revealed that care providers lacked knowledge on approaches to engage young mothers in treatment. Young mothers had poor treatment engagement, low social support, and little interest in parenting. A main characteristic of the newly designed intervention is the inclusion of age-appropriate psychoeducation supported with weekly mobile phone calls, to address treatment engagement and parenting behaviours of young mothers. Also in the outer setting, low social support from relatives was addressed with education, "as need arises" phone calls, and the involvement of "neighborhood mothers". In the inner settings, care providers' behaviour is addressed with training to increase their capacity to engage young mothers in treatment. Conclusion: A theory-based approach helped develop an age-appropriate intervention package targeting depression and parenting skills deficit among perinatal adolescents in primary maternal care and in which a pragmatic use of mobile phone was key. [ABSTRACT FROM AUTHOR]

Objective The objective of this paper is to explore policymakers and clinical managers' views on maternal health service delivery in rural Nigeria. Design This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery. Setting The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria. Participants The study participants consisted of 13 key informants who are policy- makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter. Results Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient- provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints. Conclusion This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies. [ABSTRACT FROM AUTHOR]

Expanding access to maternal, newborn and child health (MNCH) services in traditional societies is a public health challenge, often complicated by cultural and religious beliefs about what is permitted or not permitted within a faith group. This is particularly true in the Muslim majority North of Nigeria, where deep suspicions of Western public health programmes, coupled with failing and underfunded health system, have led to the emergence of a new generation of Muslim Opinion Leaders (MOLs) with counter-narratives against family planning, immunisation and nutrition programmes. This paper reports on an innovative project implemented under the Saving Lives at Birth global partnership programme, where conservative MOLs transformed as champions were engaged as health communicators to train health providers on correct religious precepts related to MNCH. A matched subject type of study design was used to compare healthcare providers' performance in control and intervention health facilities. The result indicates a significant difference both in perception and in practices between healthcare providers in intervention and control facilities, with respect to MNCH uptake. This paper highlights the need for renewed focus on engaging faith leaders and organisations in health communication and service delivery and presents a model of sustainable engagement of champions in MNCH. [ABSTRACT FROM AUTHOR]

In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework—Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation—to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services. [ABSTRACT FROM AUTHOR]

Background: Caesarean section is recommended in situations in which vaginal birth presents a greater likelihood of adverse maternal or perinatal outcomes than normal. However, it is associated with a higher risk of complications, especially when performed without a clear medical indication. Since labour attendants have no standardised clinical method to assist in this decision, statistical tools developed based on multiple labour variables may be an alternative. The objective of this paper was to develop and evaluate the accuracy of models for caesarean section prediction using maternal and foetal characteristics collected at admission and through labour. Method: This is a secondary analysis of the World Health Organization's Better Outcomes in Labour Difficulty prospective cohort study in two sub-Saharan African countries. Data were collected from women admitted for labour and childbirth in 13 hospitals in Nigeria as well as Uganda between 2014 and 2015. We applied logistic regression to develop different models to predict caesarean section, based on the time when intrapartum assessment was made. To evaluate discriminatory capacity of the various models, we calculated: area under the curve, diagnostic accuracy, positive predictive value, negative predictive value, sensitivity and specificity. Results: A total of 8957 pregnant women with 12.67% of caesarean births were used for model development. The model based on labour admission characteristics showed an area under the curve of 78.70%, sensitivity of 63.20%, specificity of 78.68% and accuracy of 76.62%. On the other hand, the models that applied intrapartum assessments performed better, with an area under the curve of 93.66%, sensitivity of 80.12%, specificity of 89.26% and accuracy of 88.03%. Conclusion: It is possible to predict the likelihood of intrapartum caesarean section with high accuracy based on labour characteristics and events. However, the accuracy of this prediction is considerably higher when based on information obtained throughout the course of labour. [ABSTRACT FROM AUTHOR]

Background: Antenatal care (ANC) services are critical for maternal health but Nigeria performs poorly in ANC utilisation compared to other countries in sub-Saharan Africa. This study aimed to assess socioeconomic inequalities in ANC utilisation and the determinants of these inequalities in Nigeria.Methods: The 2013 Nigeria Demographic and Health Survey data with 18,559 women was used for analysis. The paper used concentration curves and indices for different measures of ANC utilisation (no ANC visit, 1-3 ANC visits, at least four ANC visits, and the number of ANC visits). A positive (or negative) concentration index means that the measure of ANC utilisation was concentrated on the richer (poorer) population compared to their poorer (richer) counterparts. The concentration indices were also decomposed using standard methodologies to examine the significant determinants of the socioeconomic inequalities in no ANC visit, at least four ANC visits, and the number of ANC visits.Results: No ANC visit was disproportionately concentrated among the poor (concentration index (CI) = - 0.573), whereas at least four ANC visits (CI = 0.582) and a higher number of ANC visits (CI = 0.357) were disproportionately concentrated among the rich. While these results were consistent across all the geopolitical zones and rural and urban areas, the inequalities were more prevalent in the northern zones (which also have the highest incidence of poverty in the country) and the rural areas. The significant contributors to inequalities in ANC utilisation were the zone of residence, wealth, women's education (especially secondary) and employment, urban-rural residence, ethnicity, spousal education, and problems with obtaining permission to seek health care and distance to the clinic.Conclusions: Addressing wealth inequalities, enhancing literacy, employment and mitigating spatial impediments to health care use will reduce socioeconomic inequalities in ANC utilisation in Nigeria. These factors are the social determinants of health inequalities. Thus, a social determinants of health approach is needed to address socioeconomic inequalities in ANC coverage in Nigeria. [ABSTRACT FROM AUTHOR]

Background: Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority, particularly for sub-Saharan African countries such as Nigeria. Evidence suggests that the use of Community Health Workers (CHWs) can be effective in broadening access to, and coverage of, health services and improving MCH outcomes in such countries.Methods/design: In this paper, we report the methodology for a 5-year study which aims to evaluate the context, processes, outcomes and longer-term sustainability of a Nigerian CHW scheme. Evaluation of complex interventions requires a comprehensive understanding of intervention context, mechanisms and outcomes. The multidisciplinary and mixed-method realist approach will facilitate such evaluation. A favourable policy environment within which the study is conducted will ensure the successful uptake of results into policy and practice. A realist evaluation provides an overall methodological framework for this multidisciplinary and mixed methods research, which will be undertaken in Anambra state. The study will draw upon health economics, social sciences and statistics. The study comprises three steps: (1) initial theory development; (2) theory validation and (3) theory refinement and development of lessons learned. Specific methods for data collection will include in-depth interviews and focus group discussions with purposefully identified key stakeholders (managers, service providers and service users), document reviews, analyses of quantitative data from the CHW programme and health information system, and a small-scale survey. The impact of the programme on key output and outcome indicators will be assessed through an interrupted time-series analysis (ITS) of monthly quantitative data from health information system and programme reports. Ethics approvals for this study were obtained from the University of Leeds and the University of Nigeria.Discussion: This study will provide a timely and important contribution to health systems strengthening specifically within Anambra state in southeast Nigeria but also more widely across Nigeria. This paper should be of interest to researchers who are interested in adapting and applying robust methodologies for assessing complex health system interventions. The paper will also be useful to policymakers and practitioners who are interested in commissioning and engaging in such complex evaluations to inform policies and practices. [ABSTRACT FROM AUTHOR]

Background: The first 12 months following childbirth are a period when a subsequent pregnancy holds the greatest risk for mother and baby, but also when there are numerous contacts with the healthcare system for postnatal care for mother and baby (immunisation, nutrition, etc.). The benefits and importance of postpartum family planning are well documented. They include a reduction in risk of miscarriage, as well as mitigation of (or protection against) low birth weight, neonatal and maternal death, preterm birth, and anaemia. Objectives: The objectives of this paper are to assess patterns and trends in the use of postpartum family planning at the country level, to determine whether postpartum family planning is associated with birth interval and parity, and to identify the health services most closely associated with postpartum family planning after adjusting for socio-economic characteristics. Design: Data were used from Demographic and Health Surveys that contain a reproductive calendar, carried out within the last 10 years, from Ethiopia, Malawi, and Nigeria. All women for whom the calendar was completed and who gave birth between 57 and 60 months prior to data collection were included in the analysis. For each of the births, we merged the reproductive calendar with the birth record into a survey for each country reflecting the previous 60 months. The definition of the postpartum period in this paper is based on a period of 3 months postpartum. We used this definition to assess early adoption of postpartum family planning. We assessed variations in postpartum family planning according to demographic and socio-economic variables, as well as its association with various contact opportunities with the health system [antenatal care (ANC), childbirth in facilities, immunisation, etc.]. We did simple descriptive analysis with tabular, graphic, and 'equiplot' displays and a logistic regression controlling for important background characteristics. Results: Overall, variation in postpartum use of modern contraception was not affected over the years by age or marital status. One contrast to this is in Ethiopia, where the data show a significant increase in uptake of postpartum contraception among adolescents from 2005 to 2011. There are systematic and pervasive equity issues in the use of modern postpartum family planning by education level, place of residence, and wealth quintile, especially in Ethiopia where the gaps are very large. Disaggregation of data also point to significant sub-national variations. After adjusting for socio-economic variables, the most consistent health sector services associated with modern postpartum contraception are institutional childbirth and child immunisation. ANC is less likely to be associated with the use of modern postpartum family planning. Conclusion: Postpartum use of modern family planning has remained very low over the years, including for childbearing adolescents. Our results indicate that improving postpartum family planning requires policies and strategies to address the inequalities caused by socio-economic factors and the integration of family planning with maternal and newborn health services, particularly with childbirth in facilities and child immunisation. Scaling up systematic screening, training of providers, and generation of demand are some possible ways forward. [ABSTRACT FROM AUTHOR]

Background: From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months - about 500 days - is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. Objective and design: This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. Results: The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron-folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. Conclusions: This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay. [ABSTRACT FROM AUTHOR]

Objective: "Negotiated standards" describe a level of quality of care that is acceptable and achievable within a specific health system, based on consensus between key stakeholders. This paper presents the development of negotiated standards for effective labor and childbirth care in selected hospitals and communities in Nigeria and Uganda.Methods: A four-step development process involving different methodologies. The process included: (1) review and synthesis of internationally recognized intrapartum clinical principles and practices; (2) primary qualitative research to assess values and preferences of women and healthcare providers, and practices that align with these preferences; (3) draft contextualization of effective and ineffective behaviors to reflect values and preferences; and (4) WHO-mediated negotiations between relevant stakeholders, including community members, providers, and administrators.Results: The primary outcomes of this process were a comprehensive set of effective behaviors and clinical practices covering the main domains of quality of care, which are practical and easy to communicate, implement, and audit across all levels of healthcare delivery.Conclusion: The process demonstrates that health facilities and providers can be motivated to adopt standards of care that uphold the values and preferences of both service users and providers, while adhering to international best practices. [ABSTRACT FROM AUTHOR]

Despite recent modest progress in reducing maternal and infant mortality rates in sub-Saharan Africa, Nigeria and Malawi were still in the top 20 countries with highest rates of mortalities globally in 2015. Utilisation of professional services at delivery – one of the indictors of MDG 5 – has been suggested to reduce maternal mortality by 50%. Yet, contextual, socio-cultural and economic factors have served as barriers to uptake of such critical service. In this paper, we examined the impact of residential wealth index on utilisation of Skilled Birth Attendant in Nigeria (2003, 2008 and 2013), and Malawi (2000, 2004 and 2010) using Demographic and Health Survey data sets. The findings from multivariate logistic regressions show that women in Nigeria were 23% less likely to utilise skilled delivery services in 2013 compared to 2003. In Malawi, women were 75% more likely to utilise skilled delivery services in 2010 than in 2000. Residential wealth index was a significant predictor of utilisation of skilled delivery services over time in both Nigeria and Malawi. These findings illuminate progress made - based on which we make recommendations for achievement of SDG-3: ensure healthy lives and promote well-being for all at all ages in Nigeria and Malawi, and similar context. [ABSTRACT FROM AUTHOR]

Background: Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria's high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care. Methods: We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000-2014. A 'best-fit' framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score. Results: Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services. Conclusions: Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions. [ABSTRACT FROM AUTHOR]

Background: This paper provides insights into design and implementation of a Conditional Cash Transfer (CCT) pilot programme under the Subsidy Reinvestment and Empowerment Programme on Maternal and Child Health (SURE-P MCH) in Nigeria. The CCT day to day operations were independently assessed, from design to enrollment and pay out, in order to inform future CCT designs and implementation.Methods: This study combined a desk review of SURE-P MCH CCT operational documents and retrospective, descriptive cross-sectional survey of 314 primary beneficiaries of the CCT scheme from 29 SURE-P MCH CCT designated health facilities between June - July 2015. The programme implementation manual (PIM) and several CCT monthly reports and articles obtained from the project implementation unit (PIU) were reviewed while structured questionnaire of (16) questions was used for face-to-face interviews with (30-33) CCT beneficiaries drawn from each of eight (8) participating states of Anambra, Bauchi, Bayelsa, Ebonyi, Kaduna, Niger, Ogun, and Zamfara and the Federal Capital Territory (FCT)-Abuja. Findings were analyzed and reported using R* statistical package (version 3.1.2). Subsequently a strengths, weaknesses, opportunities and threats (SWOT) analysis was conducted to identify key challenges and possible recommendations.Results: The SWOT analysis indicated a robust design for the CCT programme, which would have enhanced operational effectiveness if implemented as designed. However, the programme faced several implementation challenges. For instance, though 65% of beneficiaries perceived CCT pay-out events to be orderly and well-organized, in some of the pilot states the events were marred with inconsistencies resulting in large crowds and increased waiting time for some beneficiaries. Similarly, only 40% of beneficiaries received the complete N5,000 (USD30) cash incentive, 28% received N1,000 (USD6) while others received either N2000 (USD12), N3000 (USD18) or N4000 (USD24).Conclusion: The CCT pilot had a robust design as a result of a successful proof of concept which preceded the pilot roll-out. However, its implementation was marred with several challenges ranging from untimely release of funds, limited monitoring and evaluation and other operational challenges. Future CCT programmes should understudy the SWOT analysis presented in this paper to improve the design and implementation of CCT programmes in Nigeria and other settings. [ABSTRACT FROM AUTHOR]

Despite increasing attention to implementation research in global health, evidence from low- and middle-income countries (LMICs) using realist evaluations, in understanding how complex health programmes work remains limited. This paper contributes to bridging this knowledge gap by reporting how, why and in what circumstances, the implementation and subsequent termination of a maternal and child health programme affected the trust of service users and healthcare providers in Nigeria. Key documents were reviewed, and initial programme theories of how context triggers mechanisms to produce intended and unintended outcomes were developed. These were tested, consolidated and refined through iterative cycles of data collection and analysis. Testing and validation of the trust theory utilized eight in-depth interviews with health workers, four focus group discussions with service users and a household survey of 713 pregnant women and analysed retroductively. The conceptual framework adopted Hurley's perspective on 'decision to trust' and Straten et al.'s framework on public trust and social capital theory. Incentives offered by the programme triggered confidence and satisfaction among service users, contributing to their trust in healthcare providers, increased service uptake, motivated healthcare providers to have a positive attitude to work, and facilitated their trust in the health system. Termination of the programme led to most service users' dissatisfaction, and distrust reflected in the reduction in utilization of MCH services, increased staff workloads leading to their decreased performance although residual trust remained. Understanding the role of trust in a programme's short and long-term outcomes can help policymakers and other key actors in the planning and implementation of sustainable and effective health programmes. We call for more theory-driven approaches such as realist evaluation to advance understanding of the implementation of health programmes in LMICs. • Implementation research using realist evaluation helps explain health programmes. • Financial incentives improve trust contributing to increased use of healthcare. • Training, remuneration and facility upgrades improve health workers' motivation. • Loss of incentives and remuneration reduces trust, but residual trust can remain. • Theory-driven evaluations can explain and help improve complex health programmes. [ABSTRACT FROM AUTHOR]

A significant reduction in maternal mortality was witnessed globally in the year 2010, yet, no significant reduction in the maternal mortality ratio (MMR) in Nigeria was recorded. The absence of accurate data on the numbers, causes and local factors influencing adverse maternal outcomes has been identified as a major obstacle hindering appropriate distribution of resources targeted towards improving maternal healthcare. This paper reports the first community based study that measures the incidence of maternal mortality in Ibadan, Nigeria using the indirect sisterhood method and explores the applicability of this method in a community where maternal mortality is not a rare event. A community-based study was conducted in Ibadan using the principles of the sisterhood method developed by Graham et al. for developing countries. Using a multi-stage sampling design with stratification and clustering, 3,028 households were selected. All persons approached agreed to take part in the study (a participation rate of 100%), with 2,877 respondents eligible for analysis. There was a high incidence of maternal mortality in the study setting: 1,324/6,519 (20.3%) sisters of the respondents had died, with 1,139 deaths reportedly related to pregnancy, childbirth or the puerperium. The MMR was 7,778 per 100,000 live births (95% CI 7,326-8,229). Adjusted for a published Total Fertility Rate of 6.0, the MMR was 6,525 per 100,000 live births (95% CI 6,144-6,909). Women in Ibadan were dying more from pregnancy related complications than from other causes. Findings of this study have implications for midwifery education, training and practice and for the first time provide policy makers and planners with information on maternal mortality in the community of Ibadan city and shed light on the causes of maternal mortality in the area. [ABSTRACT FROM AUTHOR]

Background: Maternal and Child Health is a global priority. Access and utilization of facility-based health services remain a challenge in low and middle-income countries. Evidence on barriers to providing and accessing services omits information on the role of security within facilities. This paper explores the role of security in the provision and use of maternal health services in primary healthcare facilities in Nigeria.Methods: Study was carried out in Anambra state, Nigeria. Qualitative data were initially collected from 35 in-depth interviews and 24 focus groups with purposively identified key informants. Information gathered was used to build a programme theory that was tested with another round of interviews (17) and focus group (4) discussions. Data analysis and reporting were based on the Context-Mechanism-Outcome heuristic of Realist Evaluation methodology.Results: The presence of a male security guard in the facility was the most important security factor that facilitated provision and uptake of services. Others include perimeter fencing, lighting and staff accommodation. Lack of these components constrained provision and use of services, by impacting on behaviour of staff and patients. Security concerns of facility staff who did not feel safe to let in people into unguarded facilities, mirrored those of pregnant women who did not utilize health facilities because of fear of not being let in and attended to by facility staff.Conclusion: Health facility security should be key consideration in programme planning, to avert staff and women's fear of crime which currently constrains provision and use of maternal healthcare at health facilities. [ABSTRACT FROM AUTHOR]

Background: Health care visits during pregnancy, childbirth and after childbirth may be crucial in expanding the uptake of contraceptive care in resource-poor settings. However, little is known about how health care visits influence the uptake of modern contraception in Nigeria. The focus of this paper was to examine how health care visits influence the use of contraceptives among parous women in a medically underserved setting.Methods: The study adopted a descriptive survey design. Data was collected from 411 women who gave birth between 2010 and 2015 selected through a two-stage cluster random sampling technique. Health care visits for antenatal care services, childbirth, postnatal care and modern contraceptive were dichotomised (yes, no). Descriptive analyses were performed, and percentages, frequencies and means were reported. Multiple logistic regressions were computed, and odds ratios and 95% confidence intervals were calculated.Results: Knowledge of all contraceptive methods was lowest among women who reside in rural areas. Health care visits for antenatal care (UOR 4.5; 95% CI 2.0-10.5), childbirth (UOR2.1; 95% CI 1.4-3.2) and postnatal care services (UOR 2.3; 95% CI 1.5-3.5) independently predict ever use of any contraceptive methods. Likewise, health care visits for antenatal care (UOR 5.6; 95% CI 2.1-14.8), childbirth (UOR 2.3; 95% CI 1.5-3.6) and postnatal care services (UOR 2.8; 95% CI 1.8-4.5) were independent predictors of current use of modern contraceptive methods. In the adjusted model, health care visits for antenatal care services (AOR 3.2; 95% CI 1.1-8.8) were significantly associated with the use of modern contraceptive methods.Conclusion: Health care visits significantly predict the use of modern contraceptive methods. Expanding access to health care services would potentially increase contraceptive use among childbearing women in the medically underserved settings. [ABSTRACT FROM AUTHOR]

Background: Significant knowledge gaps exist in the functioning of institutional designs and organisational practices in purchasing within free healthcare schemes in low resource countries. The study provides evidence of the governance requirements to scale up strategic purchasing in free healthcare policies in Nigeria and other low-resource settings facing similar approaches.Methods: The study was conducted at the Ministry of Health and in two health districts in Enugu State, Nigeria, using a qualitative case study design. Semi-structured interviews were conducted with 44 key health system actors (16 policymakers, 16 providers and 12 health facility committee leaders) purposively selected from the Ministry of Health and the two health districts. Data collection and analysis were guided by Siddiqi and colleagues' health system governance framework. Data were analysed using a framework approach.Results: The key findings show that supportive governance practices in purchasing included systems to verify questionable provider claims, pay providers directly for services, compel providers to procure drugs centrally and track transfer of funds to providers. However, strategic vision was undermined by institutional conflicts, absence of purchaser-provider split and lack of selective contracting of providers. Benefit design was not based on stakeholder involvement. Rule of law was limited by delays in provider payment. Benefits and obligations to users were not transparent. The criteria and procedure for resource allocation were unclear. Some target beneficiaries seemed excluded from the scheme. Effectiveness and efficiency was constrained by poor adherence to purchasing rules. Accountability of purchasers and providers to users was weak. Intelligence and information is constrained by paper-based system. Rationing of free services by providers and users' non-adherence to primary gate-keeping role hindered ethics.Conclusion: Weak governance of purchasing function limits potential of FMCHP to contribute towards universal health coverage. Appropriate governance model for strengthening strategic purchasing in the FMCHP and possibly free healthcare interventions in other low-resource countries must pay attention to the creation of an autonomous purchasing agency, clear framework for selective contracting, stakeholder involvement, transparent benefit design, need-based resource allocation, efficient provider payment methods, stronger roles for citizens, enforcement of gatekeeping rules and use of data for decision-making. [ABSTRACT FROM AUTHOR]