Improvement of Government's Free Maternal and Child Health Care

An Evidence-Based Policy Brief Who is this policy brief for? Policymakers, their support staff, Improvement of and people with an interest in the problem that this policy brief addresses Government’s Free Why was this policy Maternal and Child brief prepared? This policy brief was prepared to summarize the best available Health Care Programme evidence about the problem which it addresses and solutions to that problem using Community- This evidence- based policy brief Based Participatory includes: - A description of a health system Interventions in Ebonyi problem - Viable options for addressing this problem - Strategies for implementing these State Nigeria options

Not included: recommendations

This policy brief was prepared by the Health Policy & Syatems Research Project Team (Knowledge Translation Executive Summary Platform) Ebonyi State University, Abakaliki, Nigeria. A shorter version of this Full Report is available in the Executive Summary. Authors Chigozie Jesse Uneke PhD, MHSG Chinwendu Daniel Ndukwe MBBS, FWACP What is an Abel Abeh Ezeoha PhD evidence-based Henry Urochukwu MBBS, MSc.PH policy brief? Evidence-based policy briefs bring together global research evidence (from systematic reviews) and 29 May 2013 local evidence to inform deliberations about health policies and programmes

What is a systematic review? A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and

critically appraise the relevant research, and to collect and Ebonyi State University Ebonyi State Ministry of Health analyse data from this research Abakaliki, Nigeria Abakaliki, Nigeria

Key messages The Policy Issue

Ebonyi State introduced Free Maternal and Child Health Care Programme (FMCHCP) in 2003 in secondary and tertiary public and Faith based health facilities. The rationale behind the implementation of FMCHCP is to ensure increased and equitable access to and use of skilled maternal and child healthcare services. The aim was to address the high maternal mortality in the State. The policy is pursued against the backdrop of existing inequities in maternity and paediatric services accessibility and utilization, and is premised on the notion that financial barriers are one of the most important constraints to equitable access and use of skilled maternal and child health care. The services involved in the FMCHCP include free antenatal care (ANC) including card and antenatal drugs, free vaginal and assisted vaginal delivery (forceps and vacuum), free caesarean section (elective and emergency), free post abortion care services, free management of ectopic pregnancy and free laparotomy for obstetric complications. Despite the implementation of FMCHCP, utilization of maternity services is still poor especially in the rural areas, with over 65% of the women delivering at home. Magnitude of the problem

Although the Government of Ebonyi State, Nigeria, is implementing FMCHCP, most people, particularly in the rural areas, are unable to access, let alone to benefit from, the programme due to the following reasons: 1. The FMCHCP is implemented in designated secondary health facilities far away from majority of the rural settlements. 2. The FMCHCP is not currently seen as a programme that can go beyond the present “health facility-based” implementation approach. 3. The FMCHCP is facing severe operational problems including inadequate human resource for health, inadequate funding, out of stock syndrome, inadequate infrastructure, poor staff remuneration and lack of participation of the local government authorities in the FMCHCP. 4. There is inadequate community involvement and participation in the planning and implementation process which has resulted to a lack of community ownership of the FMCHCP. In addition to these challenges, there has never been a systematic assessment of the impact of the FMCHCP since its launch. Policy Options and implementation strategies

Policy option 1: Training of women, using participatory adult learning methods, as voluntary maternal/neonatal caregivers (VMNC), Safe motherhood promoters (SMP) or community midwives. Also training for community-based health care providers (TBAs, midwives, and CHWs). Policy option 2: Community mobilization and the empowerment of individuals and communities to create demand for quality services that respond to their needs. Family- oriented and community-oriented services support self care (Antenatal/intrapartum/postnatal Family-community care), including the adoption of improved care practices and appropriate care seeking for illness. Policy option 3: Implementation of community -based participatory interventions through community health education and mobilization to strengthen and broaden the scope of the FMCHCP by introducing the following packages which are proven to be effective : (i). Community-based birth preparedness package; (ii). Community-based newborn care package; (iii). Community-based infant and young child package.

COMPLETE REPORT Introduction and Background Information At an estimated $350 per capita annually, Nigeria still ranks near the bottom 158 out of 177 countries in the United Nations Human Development Index in terms of per capita income, with more than half of the population living in poverty [1]. Nigeria with a population of over 150million has one of the weakest health systems in the world and was ranked 187th out of 191 member states by the WHO in 2000. Due to the weak health systems, maternal and child health status in Nigeria is among the worst in Africa and has not improved substantially, and in some areas of the country, has worsened over the past decade. Nigeria’s health situation makes it a major factor in the global achievement of MDGs 4 and 5. With approximately 2.5 percent of the world’s population, Nigeria has more than 10 percent of all under-5 and maternal deaths – more than 1 million newborn, infant, and child deaths and more than 50,000 maternal deaths every year [1].

The attainment of the MDGs 4 and 5 in Nigeria is unlikely by the year 2015 with the level of maternal and child health care currently in the country [2]. Annually, an estimated 52,900 Nigerian women die from pregnancy related complications, out of a total of 529,000 global maternal deaths, thus a woman’s chance of dying from pregnancy and childbirth in Nigeria is 1 in 13 [3]. Nigeria loses 2,300 under-five year olds and 145 women of childbearing age every day, making Nigeria the second largest contributor to the under-five and maternal mortality in the world. The main causes of maternal mortality in Nigeria are: haemorrhage (23%), infection (17%), unsafe abortion (11%), obstructed labour (11%) and toxaemia/eclampsia/hypertension (11%), Malaria (11%), anaemia (11%) and others including HIV and AIDS contribute about (5%) [1,3,4]. Many of these complications occur during pregnancy, labour and delivery.

Although many of these deaths are preventable, the coverage and quality of health care services in Nigeria continue to fail women and children. Other factors underlying maternal mortality have been identified by a number of reports, these include lack of awareness about complications in pregnancy and on the need to seek medical intervention early; lack of transportation to the health facilities where maternal health care can be provided; inability to pay for services, etc [1,3,4,5]. It is therefore important that women should have access to skilled attendants at birth, as well as, access to quality obstetric care. This care should not only be accessible but also affordable [4].

There exists a wide variation in maternal mortality rate (MMR) across the six Nigeria geo- political zones, with the Northern zones generally recording higher rates than the southern zones. Likewise, there is also a marked urban-rural variation in MMR: 351/100,000 (urban) compared to 828/100,000 (rural) [5]. However, there has been a reduction in National maternal mortality rate (MMR) from 800/100,000 in 2005[4] to 545/ 100,000 according to the recent NDHS 2008 [6].

This reduction in MMR may be attributed to the various maternal and child health intervention programmes introduced by the federal and state governments. One of such intervention programmes is the Free Maternal and Child Health Care Programme (FMCHCP). A number of states in Nigeria, including Ebonyi State, introduced and have been implementing FMCHCP for close to ten years in secondary and tertiary public and private

3 health facilities. The rationale behind the implementation of FMCHCP is to ensure increased and equitable access to and use of skilled maternal and child healthcare services. The policy is pursued against the backdrop of existing inequities in maternity and paediatric care services accessibility and utilization, and is premised on the notion that financial barriers are one of the most important constraints to equitable access and use of skilled maternal and child health care [7]. The services provided in the FMCHCP of Ebonyi State include free antenatal care ANC (including card and antenatal drugs), free vaginal and assisted vaginal delivery (forceps and vacuum), free caesarean section (elective and emergency), free post abortion care services, free management of ectopic and free laparatomy for obstetric complications. Also included are free treatment for the under 5 and free vesicovaginal fistula repairs [8,9,10].

Although there is yet to be a systematic evaluation of the FMCHCP in Ebonyi State, findings from studies conducted in the two Nigerian States of Kano and Enugu indicate that the FMCHCP contributed in increased access to health services and improved maternal and child health [9,10]. There is indeed a growing global movement towards the abolition of user fees as a way to redress barriers and inequity of access to maternal and child care, ensure increased access to and use of skilled healthcare services, and ultimately improve maternal and child health [7]. In most Nigeria States including Ebonyi, despite the implementation of FMCHCP, utilization of maternal health care services is still poor especially in the rural areas, with over 65% of the women delivering at home [3,4,9,10]. It is based on this premise that the option of the implementation of community-based participatory interventions is proposed as innovative strategies to improve and sustain the government’s FMCHCP. Community participation in health interventions in Ebonyi State has been limited in scope, organization and impact. This policy brief is designed to promote the use of community participatory approach to enhance and strengthen the FMCHCP in Ebonyi State.

Definition and Magnitude of the Problem

Ebonyi State Maternal Health Statistics Ebonyi State has 13 Local Government Areas (LGAs) and the population was 2,176,947 by the 2006 national census, with a growth rate of 3.5% per annum. The State has weak health system. The life expectancy at birth in Ebonyi State was 53.8 years for females and 52.6 years for males in 1991but declined to 46 years for females and 45 years for males in 2006. The infant mortality rate (IMR) has remained high and is estimated at 99 per 1000 live births while the under age 5 mortality rate (U5MR) is 191 per 1000 live births. Ebonyi State has maternal mortality rate (MMR) of 602 per 100,000 population, which is one of the highest MMR in Nigeria [11]. This is well above the WHO estimate of 800 per 100,000 live births. Available reports indicate that the underlying factors that account for the high MMR in Ebonyi State include: poverty (especially in the rural areas), ignorance, cultural belief, inadequate health facilities, unskilled birth attendants etc [8]. These factors increase the vulnerability of pregnant women to the major causes of maternal mortality and morbidity, such as, hemorrhage, anemia, unsafe abortion, sepsis, etc.

According to the National Human Resources for Health Strategy report, Ebonyi has a doctor population ratio of 6/100,000 population and 9/100,000 population for Nurses; the distribution of health manpower is skewed towards urban populations and the primary health centres do not have sufficient manpower as recommended by regulatory agencies [11]. In much of the rural areas, traditional medical practitioners provide much of the health services; TBAs for instance are the main stay for MNCH services. This is due to near absence of health facilities in these areas. The per capita health expenditure on health is about $4, much lower than the $34 recommended by the Macroeconomic Commission on Health for the attainment

4 of the health-related MDGs. About 70% of health expenditure is from out-of-pocket and the National Health Insurance Scheme is currently not operational in Ebonyi State [11]. This situation has contributed to the very high maternal and infant mortality in Ebonyi State.

Introduction and Challenges of the FMCHCP As a result of the commitment of Ebonyi State government to addressing the high maternal mortality, the FMCHCP was introduced in the State in 2003 under the leadership of Governor Sam Egwu. The programme was however limited to the Ebonyi State University Teaching Hospital located in Abakaliki, the State capital. Although the package was comprehensive and consisted of complete obstetric care including emergency obstetric care (EOC) to the beneficiaries, unfortunately the target group, poor rural dwellers, were missed due to lack of awareness, bad road networks, poverty, first and second level delays, etc [8]. The present administration under His Excellency, Governor Martin Elechi, in a bid to revamp the FMCHCP and make it more functional and accessible, extended the services to all the major secondary health facilities located in the 13 local government areas in the State.

However, like the FMCHCP being executed in other parts of Nigeria, the FMCHCP in Ebonyi State experienced major challenges and constraints in the implementation at the various designated secondary health facilities in the 13 LGAs of the State. The key challenges and constraints include inadequate manpower; poor remuneration of staff; inadequate infrastructure and facilities; out of stock syndrome; lack of participation of the LGA authorities in the FMCHCP [8-10]:

(i). Inadequate Manpower : The FMCHCP abolished user fees and tremendously increased the number of women accessing the services without a commensurate increase in the number of health professionals attending to them. This resulted in inadequate manpower to cope with the increase in the number of patients and therefore adversely affected the quality of maternal service delivery.

(ii). Poor Remuneration of Staff: The FMCHCP increased workload for the health professionals working at the maternal and child care units. Unfortunately, there was no corresponding increase in the remuneration of the health workers. Consequently, the morale of the health workers became low and their attitudes to work very poor.

(iii). Inadequate Infrastructure and facilities: The increase in the patient flow placed so much pressure on the few available facilities and infrastructure at the secondary health facilities in the LGAs. Although some forms of upgrading was done at the secondary health facilities by the State government, the facilities were still inadequate.

(iv). Out of Stock Syndrome : Due to the weak health systems, out of stock syndrome was a frequent occurrence. This affected the delivery of maternal health services rendered at the health facilities.

(v). Lack of participation of the LGA authorities in the FMCHCP : The FMCHCP is an enormous project requiring a lot of resources to both implement and sustain. Unfortunately, because the programme is being implemented in the secondary health facilities funded by the State Government, the LGA authorities appear not to play any contributory role to the programme. This has limited the impact of the programme in terms of improving the access and scope of the programme to primary health care facilities. This is further worsened by the poor state of the primary health care facilities which are considered to be the responsibility of the third tier of government, i.e., the local government.

5 Re-launch of the FMCHCP The re-launched Free Maternal Healthcare Programme was designed as an improved package that provides qualitative and comprehensive maternal and child health services to all categories of women in Ebonyi State. The scope of the re-launched FMCHCP covers the following [8]: (i). Antenatal care (ANC) , including routine laboratory investigations and drugs. (ii). All delivery, including basic emergency obstetric care (BEOC) and emergency obstetric care (EOC). (iii). Postnatal care (iv). Family planning. (v). Ambulance services.

Her Excellency, the wife of the Executive Governor, Chief Mrs. Josephine Elechi, in addition to the re-launched FMCHCP, has the Mother and Child Care Initiative (MCCI) program that provides the enabling ground for the operation of the Free Maternal Healthcare Program through awareness creation, advocacy, financial support etc [4]. A component of the MCCI programme (Maternal Mortality Monitoring Law of Ebonyi State) encourages all pregnant women in the State to access medication in the hospitals and as well regulates the activities of quacks and other healthcare providers [4,8].

To promote the success of the FMCHCP, the present administration of Governor Martin Elechi awarded a grant to the tune of N600,000,000 (Six Hundred Million Naira) ($3.75M) to six rural private/mission hospitals to strengthen the operation of the free maternal services in their domains. The maternal health statistics from the six hospitals that received the grant are presented in Table 1.

Table 1: Maternal Health Statistics in the 6 Assisted Rural Hospitals in Ebonyi State (2006 – 2012). Source: FMCHCP Ebonyi State Ministry of Health [8] & MCCI office Government House Abakaliki (a). Antenatal Care Attendance Name of Health Centre 2006 2007 2008 2009 2010 2011 2012 RIM Ikwo 41 30 201 1,050 1,920 2653 3480 No Sudan United 2,012 3,004 5,295 11,912 1,900 No Record Record Mile 4 7,961 8,509 8,671 8,847 2,377 8804 1946 St. Vincent Ndubia 2,610 2,341 2,134 21,806 6,403 2648 2953 Presbyterian Uburu 2,731 3,232 3,320 4,301 1,945 3527 3467 Mater Afikpo 3,101 4,277 4,748 9,748 421 8896 10327 Total 18,456 21,393 24,369 57,664 14,966 26528 22173

(b). Hospital Delivery Booked Unbooked

Name of Health 2006 2007 2008 2009 2010 2006 2007 2008 2009 2010 2011 2012 Centre RIM Ikwo 4 9 17 480 984 0 0 11 68 793 298 361 Sudan No No 50 100 499 1,234 300 25 35 40 100 10 United Record Record Mile 4 1,676 2,046 2,189 2,216 624 41 53 71 146 19 3115 3636 St. Vincent 87 45 68 633 183 16 27 35 49 19 353 381 Ndubia

6 Presbyterian 276 267 270 276 108 20 7 31 70 31 343 357 Uburu Mater 100 853 870 2,270 300 5 10 6 100 30 1047 1196 Afikpo Total 2,193 3,320 3,913 7,109 2,499 107 132 234 533 902 5156 5931

(c). Maternal Deaths in the facilities Name of Health Centre 2006 2007 2008 2009 2010 2011 2012 RIM Ikwo 1 3 0 0 0 0 1 No No Sudan United 10 8 5 0 0 Record Record Mile 4 8 10 8 13 3 12 4 St. Vincent Ndubia 0 0 0 0 3 6 7 Presbyterian Uburu 8 6 5 2 0 2 0 Mater Afikpo 5 4 5 2 0 5 4 Total 32 31 23 17 6 25 16

In April 2013, the Ebonyi State Governor, Martin Elechi, disbursed the 2013 first quarter of the 14th tranche to the tune of two hundred million naira ($1,250,000) to six rural faith-based hospitals implementing the FMCHCP [12 ]. According to Governor Elechi who was represented by Health Commissioner of the state, Dr. Sunday Nwangele, during the occasion noted as follows: (i). Eighteen percent, (Thirty six million naira) stabilization fund was shared equally to the six Hospitals, (ii). Fifty percent, (One hundred million naira) implementation fund for Free maternal health services was shared in proportion of performance of each Hospital, (iii). Twenty eight percent, (Fifty six million naira) was for retention of manpower i.e., to support wage bills; (iv). Four percent, (Eight million naira) was for promotion of child Health, especially to strengthen routine immunization and other diseases control.

The breakdown of the two hundred million was disbursed to the six rural hospitals is as follows: Mile 4 Hospital received N28.0M; St Vincent Hospital, Ndubia was given N35.0M; Sudan United Mission Nigeria Reformed Church, Onuenyim Izzi received N35.2M; Rural Improvement Mission Hospital received N33.0M; Presbyterian Joint Hospital Uburu received N33.4M; and Mater Misericodae Hospitals Afikpo received N35.4M [12].

Need for improvement of the FMCHCP Implementation Strategy Although the Government of Ebonyi State Nigeria is implementing FMCHCP, most people particularly in the rural areas are unable to access let alone to benefit from the programme. This is because the FMCHCP is implemented in only six designated secondary health facilities far away from majority of the rural settlements. Secondly, the FMCHCP is not currently seen as a programme that can go beyond the present “health facility-based” implementation approach. Thirdly, the FMCHCP is facing severe operational problems including inadequate human resource for health, inadequate funding, out of stock syndrome, inadequate infrastructure and poor staff remuneration. Fourthly, there is less emphasis on

7 community involvement and participation in the implementation process which has resulted to a lack of community ownership of the FMCHCP. In addition to these challenges, the government owned secondary health facilities which were originally expected to implement the FMCHCP are not as resourced as the private ones and there has never been a systematic assessment of the impact of the FMCHCP since its launch. These challenges have adversely affected the success and sustainability of the FMHCP and stakeholders are beginning to question the relevance of the programme.

During the inauguration of the Ebonyi State Health Policy Advisory Committee in August 2011, the Commissioner for Health of Ebonyi State Dr. Sunday Nwangele stated thus:

“The most pressing area we need urgent information is concerning the Free Maternal Health Care Programme (FMHCP) administered by the State government. We need information on the impact of the programme, the cost, review of the operational/ implementation strategies. The government would like to know whether to continue the programme at the present pace, improve the operations or to scrap the programme.”

Therefore based on findings of the evaluation of impact of similar programmes showing the effectiveness of community –based participatory interventions [13-18], we propose the implementation of community-based participatory interventions to strengthen the government’s FMCHCP. Several community mobilization interventions have used a participatory approach, building on the idea that if mothers and other community members take part in decision-making and bring local knowledge, experiences and problems to the fore, they are more likely to own and sustain solutions to improve their communities’ health [13]. The rationale for using community-based interventions is based on the fact that many maternal and neonatal deaths occur at home, and could potentially be avoided by changes in antenatal and newborn care practice and better understanding of health problems. There are numerous randomized controlled trial (RCT) studies which have clearly demonstrated that community-based participatory interventions can improve maternal and child health [14-20].

Policy Options and Implementation Strategies for Addressing the Problem

In this policy brief, different policy options are suggested to establish community-based participatory approach to strengthen the government’s FMCHCP. Scientific evidence abound which indicates that this approach can improve health interventions in low income settings by promoting the following: empowerment; building organizational capacity; improving efficiency, effectiveness and sustainability; and strengthening local government [21]: (i). Empowerment of people and communities: A number of previous reports have argued that well-designed community-based projects have the potential to be more inclusive, to empower communities, including poor and marginalized groups, and strengthen linkages between civil society and government [21-23]. (ii). Improve efficiency, effectiveness and sustainability of interventions: Evidence from community-based studies indicates that community-based interventions have the potential to be more responsive to the needs and priorities of beneficiaries (allocative efficiency) [21]. The findings from the studies reported by McLeod [24] and Rawlings and colleagues [25] showed that community-based projects are comparatively cost effective (productive efficiency) because of lower levels of bureaucracy and better knowledge of local costs. (iii). Build organizational capacity at local level: . Slaymaker and colleagues [21] in their report noted that in theory, mobilization of communities to identify problems and plan and

8 manage projects helps strengthen local capacity for collective action. Furthermore McLeod and Tovo [26] demonstrated in their studies that additional benefits of community-based participatory projects are often observed beyond the scope of the original project, e.g. formation of self-help groups and micro enterprise development. (iv). Strengthen local governance: Community-driven development is increasingly being promoted as a means of strengthening state-community synergies [27]. Emerging demand- driven approaches theoretically ‘empower’ communities to command services and provide a mechanism for (re)building trust and accountability and re-establishing the ‘social contract’ between communities and government [21].

Policy Option 1: Training of women using participatory adult learning methods, as voluntary maternal/neonatal caregivers (VMNC) and Safe motherhood promoters (SMP). Also training for community-based health care providers (TBAs, midwives, and CHWs):

Implementation strategy A multidisciplinary epidemiological team can be set up consisting of medical experts, researchers and policymakers from the health ministry. Special training sessions can be organized periodically for women community organizations. The training will focus on the following: recognition of danger signs during pregnancy; labor/delivery; the postpartum period and in the newborn; prenatal care to prevent complications from occurring or becoming serious; life-saving skills in case of emergency when no other recourse exists; hemorrhage and anemia; retention of the placenta; reproductive health and sex education; care of the newborn; family planning. Criteria for the selection of SMPs & VMNC include: (i) she/he must be a married person, (ii) able to read write, (iii) accepted by residents within the community, and able to educate others. This approach has been shown to work in numerous community based interventions to improve maternal health in resource constrained communities [14-21,28,29]

Policy Option 2: Community mobilization and the empowerment of individuals and communities to demand quality services that respond to their needs. Family-oriented and community-oriented services support self care (Antenatal/intrapartum/postnatal Family- community care), including the adoption of improved care practices and appropriate care seeking for illness.

Implementation strategy: Women of child bearing age in the community can be sensitized through the health department of the various LGAs. These services can be provided by various health workers, and should be tailored to the community’s social and cultural environment. Examples of family-community care include: behaviour change communications; community mobilisation and engagement to stimulate adoption of improved antenatal, intrapartum, and postnatal care practices; care seeking for illness; and, community-based case management of illness—eg, pneumonia—by community health workers [29]. Evidence-based neonatal care practices (breastfeeding, thermal care, clean cord care), and promotion and practice of clean delivery and referral of complications (for home births); Extra home visits and support for breastfeeding and quarterly community outreaches to create demand for services [28,29].

Policy Option 3: We propose the Implementation of community -based participatory interventions to strengthen and broaden the scope of the FMCHCP by introducing the following packages which were proven as very effective in previous studies [28,29]: (i). Community-based birth preparedness package: It is a social mobilization programme to promote the behaviour of families to prepare for birth by engaging volunteers to counsel the mothers and families during home visits as well as during the community group meetings.

9 (ii). Community-based newborn care package: The package consists of service delivery component, home visitation as well as community mobilization to enhance skills on community case management of infection, home-based care of LBW, and birth asphyxia as well as orientation to mothers’ group, traditional healer and traditional birth attendant about the programme. (iii). Community-based infant and young child feeding package: is a package having counselling component on early breast feeding, exclusive breast feeding, extended breast feeding, complementary feeding and food diversification. (iv). Community-based integrated management of childhood illness package: This is a package which has a service delivery component such as the delivery of commodities as well as community participation and the promotion of positive health behaviours and enhancement of skills for home-based management of pneumonia and diarrhoea as well as orientation to mothers about the programme in the community.

Implementation strategy The implementation package will consists principally of providing technical skills to women of child bearing age as well as mothers’ groups, and traditional birth attendants for better home-based maternal and child health care. The Community Action Cycle (CAC) frame described in previous studies [28,29] can be employed to understand the community context, exploration of the issue to understand what is being currently done and why (helpful, harmful and benign practices, belief and attitudes), setting the priorities, planning together with the communities, monitoring and evaluating the progress.

Stage 1: Identifying and prioritizing problems together The women’s groups will identify and prioritize maternal and neonatal health problems at the community level via the following steps: (1). Orientation of the women to the FMCHCP improvement intervention project (2). Exploring attitudes of the women toward pregnancy and maternity and the FMCHCP. (3). Learning what the women know and do about maternal and neonatal health problems. (4). Encouraging women to think about what other women in the community know and do in relation to maternal and neonatal health problems. (5). Identifying challenges associated with access to the FMCHCP (6). Exploring and designing different ways to collect information from other women in the community. (7). Implementing woman-to-woman interviews in the home to obtain more information on maternal/child health and the FMCHCP. (8). Sharing results with the women’s groups. (9). Prioritizing the problems of maternal/child health and the FMCHCP.

Stage 2: Planning strategies together The purpose is to define strategies and actions to resolve the problems identified by the women's groups through a process of planning together via the following steps: (1). Presentation of problems by the women: The women’s groups will learn about the problems of maternal/child health and will know why they are priority problems. (2). Identifying barriers to solving the problems: The women’s groups will understand what a barrier is and will identify barriers to solving the problems of maternal/child health and the FMCHCP portrayed by the women. (3). Identifying strategies and realistic, concrete actions: The women’s groups will identify strategies and realistic, concrete actions which will help to lessen or overcome the barriers of maternal/child health. (4). Formalizing the agreements in a written document: The women’s groups will draw up a written document of the agreements they reached in order to put into practice the strategies

10 and actions for dealing with the barriers to problem-solving of maternal/child health and the FMCHCP that they have identified.

Stage 3: Training of the women Organizing training sessions on the intervention packages: (i). Community-based birth preparedness package; (ii). Community-based newborn care package; (iii). Community-based infant and young child feeding package; (iv). Community-based integrated management of childhood illness package. References 1. USAID (2008). Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response. Washington, DC 20523 2. Galandanci H, Ejembi C, Iliyasu Z, Alagh B, Umar U. Maternal health in Northern Nigeria—a far cry from ideal. BJOG 2007;114:448–452. 3. Integrated Maternal, Newborn and Child Health Strategy. Federal ministry of Health 2007, Abuja. 4. Ebonyi State Mother and Child Care Initiative (MCCI) Nigeria. Documentation commissioned by The United Nations Population Fund (UNFPA). Final Report – October 2010 5. The Maternal Newborn Roadmap. Federal Ministry of Health, 2005 Nigeria. 6. National Population Commission (Nigeria). Nigeria Demographic and Health Survey 2008 . Abuja, Nigeria: National Population Commission and ICF Macro 7. Kuumuori G. Barriers to accessing and using formal antenatal, delivery and postnatal care services in Ghana in the context of a free maternal healthcare policy. Ethox Centre, University of Oxford, Uk. 8. Ministry of Health and Environment, Abakaliki, Ebonyi State. Ebonyi State Free Maternal Healthcare Program at a Glance. Available at: http://www.ebonyionline.com/zzz-profile-ebonyi-free-maternal-healthcare-program.html 9. Okeibunor JC, Onyeneho NG, Okonofua FE. Policy and Programs for Reducing Maternal Mortality in Enugu State, Nigeria Afr. J. Reprod. Health 2010; 14[3]: 19-30. 10. Galadanci HS, Idris SA, Sadauki HM, Yakasai IA. Programs and Policies for Reducing Maternal Mortality in Kano State, Nigeria: A Review . Afr. J. Reprod. Health 2010; 14[2]: 31-36 11. Ministry of Health, Ebonyi State. State Strategic Development Plan 2010-2015. Ebonyi State Ministry of Health Abakaliki. 2010. 12 . Orient Newspaper. Ebonyi To Spend N600m On Rural Health Programme. Orient Daily on April 22, 2013. Available at: http://orientnewspaper.com/ebonyi-to-spend-n600m-on-rural- health-programme/ 13. Howard-Grabman , et al: Demystifying community mobilisation: an effective strategy to improve maternal and newborn health. 2007 [http://pdf.usaid.gov/pdf_docs/PNADI338.pdf]. 14. Tripathy P, Nair N, Mahapatra R, Rath S, Gope RK, Rath S, Bajpai A, Singh V, Nath V, Ali S, Kundu AK, Choudhury D, Ghosh S, Sarbani S, Sinha R, Pagel C, Costello A, Houweling TA, Prost A. Community mobilisation with women's groups facilitated by Accredited Social Health Activists (ASHAs) to improve maternal and newborn health in underserved areas of Jharkhand and Orissa: study protocol for a cluster-randomised controlled trial. Trials. 2011;12:182. 15. Kumar V, Mohanty S, Kumar A, Misra R, Santosham M, et al: Effect of community- based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet 2008, 372:1151-1162. 16. Tripathy PK, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S, Rath S, Gope R, Mahto D, Sinha R, Lakshminarayana R, Patel V, Pagel C, Prost A, Costello A: Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in

11 Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010, 375:1182- 1192. 17. Manandhar D, Osrin D, Shrestha B, Mesko N, Morrison J, et al: Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster randomized controlled trial. Lancet 2004, 364:970-979. 18. Lewycka S, Mwansambo C, Kazembe P, Phiri T, Mganga A, Rosato M, Chapota H, Malamba F, Vergnano S, Newell ML, Osrin D, Costello A: A cluster randomised controlled trial of the community effectiveness of two interventions in rural Malawi to improve health care and to reduce maternal, newborn and infant mortality. Trials 2010, 11:88. 19. Shah More N, Bapat U, Das S, Patil S, Porel M, Vaidya L, Koriya B, Barnett S, Costello A, Fernandez A, Osrin D: Cluster-randomised controlled trial of community mobilisation in Mumbai slums to improve care during pregnancy, delivery, postpartum and for the newborn. Trials 2008, 9:7. 20. Grabman L, Seoane G, Davenport C. The Warmi Project: a 6. participatory approach to improve maternal and neonatal health: An implementer’s manual. Westport: John Snow International, Mothercare Project, Save the Children;2002. 21. Slaymaker T, Christiansen K, Hemming I. Community-based approaches and service delivery: Issues and options in difficult environments and partnerships. Overseas Development Institute. 2005. Available at: www.odi.org.uk/resources/docs/3822.pdf 22. Narayan, Deepa (1995) Designing Community Based Development. Washington DC: World Bank. 23. Alkire, S. et al. (2004) ‘Community-Driven Development’, CDD Chapter of the PRSP Sourcebook. 24. McLeod, Dinah (2003) Community-Based Social Services: Practical Advice Based upon Lessons from Outside the World Bank, Washington DC: Social Protection Unit The World Bank. 25. Rawlings, Laura B, Lynne Sherburne-Benz and Julie van Domelen (2004) Evaluating Social Funds. A Cross-Country Analysis of Community Investments Washington DC: World Bank. 26. McLeod, Dinah and Maurizia Tovo (2001) Social Services Delivery through Community- Based Projects, Washington DC: World Bank. 27. Das Gupta, M., H. Grandvoinnett and M. Romani (2004) ‘State-Community Synergies in Community-Driven Development’, Journal of Development Studies , 40(3), pp.27-58. 28. Howard-Grabman L, Seoane G, Davenport C, MotherCare, Save the Children: The Warmi Project: a participatory approach to improve maternal and neonatal health: An implementer's manual . Westport: John Snow International, Mothercare Project, Save the Children; 2002. 29. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L; Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005;365(9463):977-88.