A post from the Stillbirth Advocacy Working Group stillbirth series by Dr. Fatima Lamishi Adamu and Dr. Adetoro Adegoke
Over the past two decades, substantial progress has been made in reducing the stillbirth rate around the world. However, in some regions, population growth is outpacing the decrease in stillbirth rates. Sub-Saharan Africa is one of two regions where that is happening – and its portion of the global number of stillbirths has increased from 27% in 2000 to 42% in 2019(i).
With its fast-growing population, Nigeria has the highest rate of stillbirth in sub-Saharan Africa and is struggling to sustain progress in reducing stillbirth rates – particularly in the Northern states. Limited access to trained health workers is a key contributing factor. The 2013 Demographic and Health Survey in Nigeria reported that 55% of pregnant women in the North West region of the country received no antenatal care, and 87.5% delivered their babies at home (compared to 20% in the South East).
Improving access to qualified female nurses and midwives in rural areas was the focus of the Women for Health Programme (W4H), a UK Aid-funded programme that ended in October 2020 after eight years. Female health workers are needed because social norms in many northern communities mean that women can only be attended by other women.
Loss of a child, future midwife
One of the beneficiaries of W4H had herself suffered the consequences of this situation. Hauwa, from Katsina state, lost her first child. She started bleeding during pregnancy and she knew she needed to be checked by a trained health worker. Her husband refused to allow her to see the community’s only health worker, as he was a man. Hauwa was eventually taken to the hospital but lost her baby. Hauwa’s husband later divorced her because she had been cared for there by a male nurse.
Hauwa’s experiences made her want to become a midwife and help other women like her to receive appropriate, timely care in their own community. But as a rural woman she faced many barriers that W4H was specifically designed to address – including changing social norms so that women could leave their communities to study and be accepted on return to serve as trained health workers.
Hauwa was supported by W4H’s key intervention – the Foundation Year Programme (FYP)– a year-long study and support initiative that helped her to meet the entrance requirements at one of Katsina’s health training colleges. Today she is a qualified midwife.
Changing social norms
In its eight years, W4H worked with nearly 1,000 communities to change social norms. W4H worked with traditional and religious leaders to change deep-seated attitudes, practices and beliefs about the value of health workers and about appropriate roles and behaviours for women. W4H drew on cultural values and local knowledge to not only get the traditional and religious leaders, but also the state and local governments, heads of training institutions, and communities to throw their weight behind the programme.
In many rural communities in the six W4H-supported states, women can now be both mothers and professional people too. By the time the programme ended, W4H had recruited 2,801 women like Hauwa. Of these, 556 had so far graduated and 78% of them had secured jobs serving rural communities.
Early evidence (qualitative and quantitative) suggests that the returning FYP graduates are having an impact on the numbers of women accessing health services and antenatal care, on the uptake of modern family planning methods, and saving the lives of mothers and babies.
Foundations for sustainable change
Crucially, the UK Aid-funded programme has laid the foundation for sustainable change in Northern Nigeria. The programme’s principal achievements include:
- Increasing the combined student capacity of the 24 training colleges in six states (Borno, Jigawa, Kano, Katsina, Yobe, Zamfara) by more than 250%, increasing the proportion of female students to around 60% and graduation rates to above 90%.
- Securing the support of state governments, which have taken over funding and coordinating all the W4H interventions – passing laws to ensure support for the FYP and training colleges is sustained.
- A total of £22.21 million has been invested by state governments in supporting the FYP and training colleges, going a long way towards matching the UK Aid total spending of £33.86 million.
- A W4H qualitative survey carried out among FYP recruits found that 95% say their communities now show greater support for women’s employment and 82% say the FYP has enabled them to develop careers and become local champions.
- Six neighbouring states that were not part of W4H have begun to establish their own FYP based on the W4H model.
- A powerful partnership was established with the Nursing and Midwifery Council of Nigeria, which is scaling up elements of the programme across the whole of Nigeria.
- A centre of excellence in Human Resources for Health (HRH) has been set up in Kano state to share learning and support scaling up of the W4H model.
- Women for Health interventions have contributed to Nigeria’s progress in meeting WHO’s global HRH 2030 aim for achieving universal health coverage. W4H has contributed to nine of the 13 global milestones – and at least 10 of the 14 recommendations.
Women for Health leaves a sustainable legacy and marks significant progress towards universal health care for underserved communities in Northern Nigeria.
Lessons learnt
- HRH challenges need a holistic and sustained approach – achieving sustainable results in HRH requires tackling many interlinked issues simultaneously over an extended period of time. Pursuing whole system strategies creates synergies that cannot be achieved with a ‘silver bullet’ approach pursuing just one or two recommendations at a time.
- Focus on sustainability from the start – W4H was thinking about and planning for exit and sustainability from the beginning. We engaged with stakeholders from all levels over a long period of time, involving them in genuinely shaping the programme. The pay-offs were the commitment and ownership shown by stakeholders – contributing to success and sustainability.
- Leverage cultural values to encourage buy-in – W4H used its understanding of the local context to get government buy-in for programme initiatives by invoking Northern Nigerian sentiment and cultural values, tapping into a sense of Northern ownership and accountability for resolving Northern problems. We also linked cultural and religious values around protecting women to the need to invest in education for female health workers.
- Consider trauma when working in conflict-affected areas – in its final two years, W4H expanded into conflict-affected Borno state. Working in areas affected by ongoing armed conflict is deeply challenging. For W4H, it involved designing interventions to address trauma and adapting our community engagement approach in contexts where communities and populations were disrupted and displaced, and where insurgents controlled access to some areas.
- Negotiate counterpart funding contributions – agreeing counterpart funding for infrastructure projects and other initiatives proved an extremely effective way to boost state governments’ interest, commitment, and sense of ownership in programme interventions. We used the offer of what W4H could provide as a negotiating tool to get governments and partners to commit to putting their own resources in too. This paved the way for a complete handover to state governments.
- Make strategic use of research and evidence – W4H used research and evidence to help shape its strategies, ensured they were effective and gave them legitimacy. For instance, we investigated the root causes of the shortage of female health workers, as well as identifying and overcoming barriers to retaining rural midwives, and how training colleges could become more responsive to the needs of women students and staff. We also produced our own research on community health workers which influenced national policy.
The Stillbirth Advocacy Working Group was founded by the Partnership for Maternal, Newborn and Child Health, and is co-chaired by the International Stillbirth Alliance and the London School of Hygiene & Tropical Medicine. Email co-chairs Hannah Blencowe or Susannah Leisher at hannah-jayne.blencowe@lshtm.ac.uk or shleisher@aol.com to learn more, or sign up to join the group here!
