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In Nigeria the Zaria Prevention of Maternal Mortality (PMM) team one of 12 multidisciplinary teams in the international PMM Network conducted a series of interventions to reduce maternal mortality. After conducting a 1989 situation analysis to identify barriers faced by women needing emergency obstetric care interventions were designed to improve the quality of care at the health facilities. Then in 1995 efforts were made to address the community-level barriers of cost and transportation difficulties. A revolving emergency loan fund was established in each project community in early 1995. The interest-free loans were financed by community contributions and were restricted to use by women with obstetric complications who had repaid previous loans from the fund. The loans had a 6-month repayment grace period a 24-month repayment period and a 12-month residency requirement. The second community intervention involved mobilizing transport owners to provide an affordable round-the-clock community transport service. Community leaders introduced both plans to the villagers through an intensive campaign. Data on program operation from March to December 1995 show that the amount of money raised at each fund-raising event increased from US$572 to $8116 to $11803. By the third event 81 community members pledged lifetime contributions totaling $18.45/day. In the same period 18 loans were made ranging from $52 to $69; repayment data are unavailable. Participation of vehicle owners also increased from 3 to 15 to 40 with 28 vehicle owners pledging permanent participation. Women with complications began using the services as soon as they were available. The cost of these community interventions was $5681 with 60% covered by the community and 40% by the PMM team. The community interventions failed to reverse the downward trend in health facility utilization but may have slowed it. Involvement of traditional community leaders in the intervention should promote project sustainability.

Preliminary studies: Facility review at the secondary hospital in Makarfi revealed a lack of drugs and skilled personnel and delays in treating and referring women with obstetric complications. Interventions: In 1994, maternity facilities were renovated, a revolving drug fund was introduced, midwives were trained and an ambulance was restored to service. Attempts to secure a physician with skills in treating obstetric emergencies were unsuccessful. Prior to these activities, obstetric services at the referral hospital were improved. Community interventions focused on improving utilization by women with complications. Results: Between 1990 and 1995, substantial increases occurred in antenatal attendance (2517 to 5565 per year) and deliveries (325 to 1952 per year). The number of women with complications seeking care at this facility, however, dropped from 85 in 1990 to 28 in 1995. Referrals to higher level facilities increased from four in 1990 to 17 in 1995. Costs: The cost of the interventions was approximately US $32 000. Ninety-eight percent was paid by the government and 2% by PMM. Conclusions: Improving the quality of maternity services can increase utilization by women with uncomplicated pregnancies. However, utilization of emergency services appears to be influenced by other factors, such as the ability to treat obstetric complications and prevailing economic conditions. © 1997 International Federation of Gynecology and Obstetrics