Coverage and equity of maternal and newborn health care in rural Nigeria, Ethiopia and India.

BACKGROUND: Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India. METHODS: We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity. RESULTS: In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%-25%) to 43% (95% CI 33%-54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%. INTERPRETATION: Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.

Monitoring childbirth care in primary health facilities: a validity study in Gombe State, northeastern Nigeria.

BACKGROUND: Improving the quality of facility-based births is a critical strategy for reducing the high burden of maternal and neonatal mortality and morbidity across all settings. Accurate data on childbirth care is essential for monitoring progress. In northeastern Nigeria, we assessed the validity of childbirth care indicators in a rural primary health care context, as documented by health workers and reported by women at different recall periods. METHODS: We compared birth observations (gold standard) to: (i) facility exit interviews with observed women; (ii) household follow-up interviews 9-22 months after childbirth; and (iii) health worker documentation in the maternity register. We calculated sensitivity, specificity, and area under the receiver operating curve (AUC) to determine individual-level reporting accuracy. We calculated the inflation factor (IF) to determine population-level validity. RESULTS: Twenty-five childbirth care indicators were assessed to validate health worker documentation and women's self-reports. During exit interviews, women's recall had high validity (AUC≥0.70 and 0.75

Newborn resuscitation in Gombe State, northeastern Nigeria.

BACKGROUND: Basic newborn resuscitation for babies not breathing at birth is a highly effective intervention and its scale-up identified as a top research priority. However, tracking progress on the scale-up and coverage of this intervention is compromised by limitations in measuring both the number of newborns receiving the intervention and the number of newborns requiring the intervention. Using data from a facility and birth attendant survey in Gombe State, Nigeria, we aimed to advance the measurement agenda by developing a proxy indicator defined as the "percent of newborns born in a facility with the potential to provide newborn resuscitation". METHODS: The indicator's denominator was defined as: the total number of births in facilities during a defined time period (facility records). The numerator was constructed from the number of those births that occurred in appropriately equipped facilities (facility inventory), where a birth attendant demonstrated basic resuscitation competence (assessed by a simulation exercise). The proportion of facility-births that took place in a setting with the potential to provide newborn resuscitation was then calculated. RESULTS: The analysis included 17 383 births that occurred during May-October 2015 in 117 primary and referral facilities surveyed in November 2015. Overall 81% of the facilities did not have all items of essential equipment required for resuscitation; the items of equipment least frequently present included a timing device and resuscitation bag with two sizes of neonatal face mask. Only 3% of 117 birth attendants interviewed demonstrated competence to undertake resuscitation, all of whom were classified as skilled attendants and worked in referral facilities. We found that 20% of the 17 383 births took place in a facility with the potential to provide lifesaving resuscitation care. CONCLUSIONS: The indicator definition of neonatal resuscitation presented here responds to the need to advance the measurement agenda for newborn care and importantly adjusts for the volume of births occurring in different facilities. Its application in this setting revealed substantial missed opportunities to providing lifesaving care and highlights the need for a greater focus on input as well as process quality in all levels of health facilities.