Safety, Quality, and Acceptability of Contraceptive Subdermal Implant Provision by Community Health Extension Workers Versus Nurses and Midwives in Nigeria: Protocol for a Quasi-Experimental, Noninferiority Study.

BACKGROUND: As part of its Family Planning 2020 commitment, the Nigerian government is aiming for a contraceptive prevalence rate of 36% by 2018, and in 2014, approved a policy to allow community health extension workers (CHEWs), in addition to doctors, nurses, and midwives, to provide contraceptive subdermal implants. There is a lack of rigorous evidence on the safety of long-acting reversible contraceptive provision, such as implants, among lower cadres of health providers. OBJECTIVE: This study aimed to compare implant provision by CHEWs versus nurses and midwives up to 14 days post insertion. METHODS: The quasi-experimental, noninferiority study will take place in public sector facilities in Kaduna and Ondo States. In each state, we will select 60 facilities, and from these, we will select a total of 30 nurses and midwives and 30 CHEWs to participate. Selected providers will be trained to provide implant services. Once trained, providers will recruit a minimum of 8125 women aged between 18 and 49 years who request and are eligible for an implant, following comprehensive family planning counseling. During implant insertion, providers will record data about the process and any adverse events, and 14 days post insertion, providers will ask 4410 clients about adverse events arising from the implant. Supervisors will observe 792 implant insertions to assess service provision quality and ask clients about their satisfaction with the procedure. We will conclude noninferiority if the CI for the difference in the proportion of adverse events between CHEWs and nurses and midwives on the day of insertion or 14 days post insertion lies to the right of -2%. RESULTS: In September and October 2015, we trained 60 CHEWs and a total of 60 nurses and midwives from 12 local government areas (LGAs) in Kaduna and 23 LGAs in Ondo. Recruitment took place between November 2015 and December 2016. Data analysis is being finalized, and results are expected in March 2018. CONCLUSIONS: The strength of this study is having a standard care (nurse and midwife provision) group with which CHEW provision can be compared. The intervention builds on existing training and supervision procedures, which increases the sustainability and scalability of CHEW implant provision. Important limitations include the lack of randomization due to nurses and midwives in Nigeria working in separate types of health care facilities compared with CHEWs, and that providers self-assess their own practices. It is unfeasible to observe all procedures independently, and observation may change practice. Although providers will be trained to conduct implant removals, the study time will be too short to reach the sample size required to make noninferiority comparisons for removals. TRIAL REGISTRATION: ClinicalTrials.gov NCT03088722; https://clinicaltrials.gov/ct2/show/NCT03088722 (Archived by WebCite at http://www.webcitation.org/6xIHImWvu)

Safety, Quality, and Acceptability of Contraceptive Implant Provision by Community Health Extension Workers versus Nurses and Midwives in Two States in Nigeria.

Task sharing is a strategy with potential to increase access to effective modern contraceptive methods. This study examines whether community health extension workers (CHEWs) can insert contraceptive implants to the same safety and quality standards as nurse/midwives. We analyze data from 7,691 clients of CHEWs and nurse/midwives who participated in a noninferiority study conducted in Kaduna and Ondo States, Nigeria. Adverse events (AEs) following implant insertions were compared. On the day of insertion AEs were similar among CHEW and nurse/midwife clients-0.5 percent and 0.4 percent, adjusted odds ratio (aOR) 0.92 (95 percent CI 0.38-2.23)-but noninferiority could not be established. At follow-up 6.6 percent of CHEW clients and 2.1 percent of nurse/midwife clients experienced AEs. There was strong evidence of effect modification by State. In the final adjusted model, odds of AEs for CHEW clients in Kaduna was 3.34 (95 percent CI 1.53-7.33) compared to nurse/midwife clients, and 0.72 (95 percent CI 0.19-2.72]) in Ondo. Noninferiority could not be established in either State. Implant expulsions were higher among CHEW clients (142/2987) compared to nurse/midwives (40/3517). Results show the feasibility of training CHEWs to deliver implants in remote rural settings but attention must be given to provider selection, training, supervision, and follow-up to ensure safety and quality of provision

Prière pour l’intervention divine: La réalité « des trois délais » au nord du Nigéria.

This paper describes how pregnant women in three northern Nigerian communities responded to maternal complications that occurred outside of a hospital setting. The sample consisted of 322 women who had recently delivered, of which 15% had at least one complication. Thirty-seven percent of women described antepartum or postpartum haemorrhage. Over 60% of women went to a health care facility, but 35% first tried herbal remedies and another 20% simply waited for their husband to return. The median interval between recognizing the problem and deciding to seek help was two hours. It took approximately one to two hours to reach the hospital and upon arrival, most respondents got care in one to two hours. Rural communities clearly have their own hierarchy of appropriate actions in the face of a household emergency which need to be understood in order to develop creative intervention strategies to reduce unnecessary risks to the life of a motherCette étude fait une description de la manière dont les femmes dans les trois communautés du nord du Nigéria ont réagi aux complications maternelles qui se produisent en dehors du milieu hospitalier. L’échantillon comprenait 322 femmes qui venaient récemment d’accoucher, dont au moins 15% avaient une complication. Trente-cinq pourcent des femmes ont décrit l’hémorragie de l’ante-partum ou de post-partum. Plus de 60% des femmes ont fréquenté un établissement de santé, mais trente-cinq pourcent ont essayé les remèdes à base de plantes et un autre 20% n’ont fait qu’attendre que leurs maris rentrent. L’intervalle moyen entre la reconnaissance du problème et la décision de rechercher l’aide était deux heures. On mettait presque deux heures pour arriver à l’hôpital et une fois là-bas, la plupart des interrogées ont reçu des soins au cours d’une heure ou deux. Les communautés rurales ont clairement leur propre hiérarchie d’actions appropriées face à une urgence familiale qu’on doit comprendre afin de développer des stratégies de l’intervention créatrice pour réduire les risques inutiles de la vie d’une mèr

Disponibilité et utilisation des services de soins obstétriques d’urgence dans trois communautés dans l’état de Kaduna, au nord du Nigéria.

Maternal mortality ratios often reflect on the quality and availability of emergency obstetric care (EmOC) services. Ten health facilities in Kaduna State were assessed to determine their capacity to provide EmOC. Each community had the recommended number of both primary and secondary health facilities per population. All secondary health facilities had 24-hour services staffed by at least one doctor and one nurse/midwife per shift, and were able to perform most signal functions of EmOC in the three months preceding the survey. However, no primary health centres (PHC) were open 24 hours, and their performance of EmOC in the three months preceding the survey was near zero. Thus the presence of functional secondary hospitals is not enough to reduce maternal mortality in communities where women have to overcome numerous barriers to reach a hospital. If shortages of personnel, equipment and supplies in PHCs were resolved, 24-hour services could lead to a sharp reduction in maternal and infant mortality among rural women in northern NigeriaLes rapports de la mortalité maternelle reflètent souvent la qualité et la disponibilité des services de soins obstétriques d‟urgence (SSOU). Nous avons évalué dix établissements de santé dans l‟état de Kaduna afin de déterminer leur capacité pour assurer les SSOU. Chaque communauté disposait d‟un nombre d‟établissements primaires et secondaires par population. Tous les établissements de santé secondaires avaient de services de 24 heures qui avaient comme personnel un médecin, et une infirmière/sage-femme par poste et qui étaient capables d‟exercer la plupart des signal-fonctions des SSOU dans les trois mois avant l‟enquête. Néanmoins, aucun centre de soins primaires (CSP) n‟était ouvert pour 24 heures et leur performance des SSOU dans les trois mois avant l‟enquête était presque zéro. Ainsi, la présence des hôpitaux secondaires ne suffit pas pour réduire la mortalité maternelle dans les communautés où les femmes doivent surmonter beaucoup d‟obstacles pour arriver à l‟hôpital. Si les problèmes de manque de personnel, d‟équipements et d‟approvisionnement dans les CSPs sont résolus, les services de 24 heures pourraient amener une réduction remarquable dans la mortalité maternelle et infantile chez les femmes rurales au nord du Nigéri