Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

Abstract

The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, how, why and at what cost. We believe that better and policy-relevant evidence will make development more effective and improve people's lives. 3ie impact evaluations3ie-supported impact evaluations assess the difference a development intervention has made to social and economic outcomes. 3ie is committed to funding rigorous evaluations that include a theory-based design, use the most appropriate mix of methods to capture outcomes and are useful in complex development contexts. About this report SummaryLimited availability of skilled providers, particularly in rural areas, is thought to be an important constraint to increasing rates of use of maternal and child health services in low-and middle-income countries. There are, however, few well-identified studies of the relationship between the supply of skilled workers and outcomes. In this project, we studied the effects of a government program in Nigeria that sought to alleviate supply-side constraints by deploying skilled midwives to primary health facilities in rural communities, to provide round-the-clock access to skilled care.We evaluate the impact of the Midwives Service Scheme (MSS), a government program introduced in 2009 to increase access to skilled care in underserved rural areas in Nigeria. At rollout, the MSS deployed nearly 2,500 midwives to 652 primary health care centers across 36 states. To evaluate the impact of the program, we surveyed 7,104 women with a birth within the preceding five years in 386 communities across 12 states. The intervention group consisted of communities that participated in the initial rollout; the comparison group consisted of communities that would receive the program approximately three years later. To understand implementation challenges and contextualize the quantitative results, we carried out a nested qualitative study in three states, consisting of in-depth interviews and focus group discussions with policymakers, providers, childbearing women, and community stakeholder groups.Overall, we found that the program's effects were smaller than anticipated. The main effect was a 7.3-percentage-point increase in antenatal care use in program clinics (about 12 percent relative to baseline levels) and a 5-percentage-point increase in overall use of antenatal care (6 percent relative to baseline levels) within the first year of the program. We found suggestive but not conclusive evidence of a small increase in skilled birth attendance, but this was confined to the south, where there were fewer challenges with midwife retention. We did not find any significant improvements in postnatal visits or child immunizations. Given this, it is not surprising that we did not find any evidence of improvements in maternal and child health.Our data allow us to shed some light on why ...

The spillover effect of midwife attrition from the Nigerian midwives service scheme

“…This model relies on the assumption that respondents did not select into either of these periods. [2, 3] It also allows us to “sort” eligible respondents by their delivery year, which makes trends in use of obstetric services more obvious. Our first step was to use the ITS model to assess trends in use of obstetric services among rural respondents.…”

“…private sector clinics or non-use/home). [2, 3] Next, we used the ITS model to assess trends in use of obstetric services among urban respondents. Under the null hypothesis, there should be no changes.…”

“…[1–4] This mobilization and deployment may have increased the pre-existing national and rural midwives’ workforce by about 3% and 9% respectively (see Table 1), and each clinic was supposed to receive four midwives who would work in shifts to provide 24-h coverage. [2, 6] Despite its large scope, the scheme had a limited impact on use of obstetric services. [1–3] For instance, Okeke et al (2016) showed that in its first year, the scheme increased use of antenatal services at rural public-sector clinics by 5-percentage points, but had no effect on the use of delivery services at these clinics.…”

“…[1–3] For instance, Okeke et al (2016) showed that in its first year, the scheme increased use of antenatal services at rural public-sector clinics by 5-percentage points, but had no effect on the use of delivery services at these clinics. [2, 3] However, little is known about whether these changes were driven by women who would not have sought antenatal care otherwise, or by women who moved from private sector clinics (which have the lowest number of midwives per capita [see Table 1] but may offer higher quality care at higher out of pocket costs]), drawn by the potentially lower healthcare cost. [7] This difference is important because women in the former group were the scheme’s intended beneficiaries, and are more likely to affect maternal health indicators than those in the latter.…”

Implications of the SURE-P MCH National Village Health Worker Experience in Northern Nigeria for the Road Map for Village Health Workers in Nigeria

“…Experience with the existing Federal Government Midwives Service Scheme (MSS) showed that providing midwives in rural clinics was not enough to encourage women to utilize services at PHC facilities [10,11].…”