Antenatal care as a determinant of perinatal mortality in Nigeria: population-based study

Research Report Submitted To the Faculty of Humanities, University of the Witwatersrand Johannesburg, In Fulfilment of the Requirements for the Award of Degree of Masters of Arts in Demography and Population Studies Academic Year, 2014The World Health Organization has recommended focused antenatal care as a strategy for reducing the burden of perinatal mortality and for the overall improvement of maternal and child health. Fragmentary studies in Nigeria indicate that lack of ANC or inadequate ANC is a predictor of perinatal death. However, most of these studies are hospital-based and suffer heavily from selection bias and therefore do not adequately represent the general population. This study examined the association between focused antenatal care and perinatal mortality in Nigeria. Data Source and Methods The data for this study comes from the 2013 Nigeria Demographic and Health Survey (DHS). The 2013 Nigeria DHS is the fifth round of nation-wide organized data collection system supported by USAID and implemented by the National Population Commission (NPC 2014). The 2013 survey consists of nationally representative sample of 38,945 women aged 15- 49years and 17,359 men aged 15-59 years living in 38,904 households. The unique feature of the 2013 survey is the collection of information that allows the estimation of perinatal mortality possible. The main outcome variables are stillbirth (death of fetus after 7months of pregnancy or 22weeks of gestation), early neonatal death (death within 6days of delivery) and perinatal mortality (sum of stillbirths and early neonatal death). The main exposure variable is having at least four antenatal care visits in the most recent pregnancy within the five year period preceding the survey as recommended by WHO. Cox proportional hazard models were fitted to answer the research question. Results There were 396 stillbirths and 925 early neonatal deaths and use of focused ANC is 61%; perinatal mortality rate as a whole is 41 per 1000 births. About 29% of all the early neonatal deaths occurred on the day they were born while 61% within 48 hours of delivery. Use of ANC varies significantly with maternal age, geopolitical zone (North/South), place of residence (rural/urban), maternal education, wealth index, religion, and parity, sex of household head, marital status and type of marriage (polygyny/monogamy). Further, perinatal mortality rate vary according to some previously established trends: more at the extremes of maternal ages, higher in northern than in the southern geopolitical zone, highest among those with primary level of education and among lowest wealth quintile; among parity one and five or more, male child, very small babies and small babies (<2.5Kg) and those delivered in health facility. In the final model, factors significantly reducing the risk of perinatal mortality are use of focused ANC (HR=0.69, 95%CI: 0.65-0.73); being in the middle or rich wealth quintile (HR=0.87, 95%CI: 0.83-0.92); living in southern zone of the country (HR=0.87, 95%CI: 0.84- 0.89); being of parity between two and four (HR=0.91, 95%CI: 0.83-0.99); having had a urine test (HR=0.86, 95%CI: 0.81-0.91) and receiving all the six components of antenatal care (HR=0.18, 95%CI: 0.13-0.25). Those factors found to increase the risk perinatal death include living in rural area of the country (HR=1.32, 95%CI: 1.27-1.38); having between one and three cowives (HR=1.21, 95%CI: 1.17-1.26) having had a complication during the pregnancy (HR= 1.20, 95%CI: 1.16-1.25); having a female as the head of the household (HR=1.05, 95%CI: 1.02- 1.09) and taking iron tablets for more than six months (HR=1.24, 95%CI: 1.15-1.34). Conclusion The results of the analysis show that use of focused ANC significantly reduces the risk of perinatal mortality by about 31%; varying between 26% (risk reduction for early neonatal death) and 28% (risk reduction for stillbirths). Other factors that are significantly associated with reduction of perinatal mortality are residing in Southern part of the country, being of parity of between two and four, being in the middle and/or rich wealth quintile, having had a urine test during ANC visits and receiving all the six elements of antenatal care. Policy implication This results calls for the more investment in maternal and child health services particularly antenatal care to make it more easily accessible in the overall framework of improving maternal and child health. It specifically implies that socioeconomic development programs should target basic schooling (especially female education), economic welfare/poverty eradication, women empowerment as well as allocating more health resources in the disadvantaged rural areas and Northern part of Nigeria. Research implication While this research has corroborated the recommendations of WHO it has also opened up new areas of future research. There is the need to test the validity of World Health Organization’s recommendations on the role of focused ANC on perinatal mortality using more advanced statistical methods and designs such multi-level modelling, instrumental variable and propensity score matching. To have a smooth transition from research to practice, operations research have to be conducted in specific cultural and health systems contexts to deal with issues specific to these contexts. Such operations research will involve assessing the capacity of the health system on how to implement the new model of ANC in terms infrastructure, staffing, training and re-training of staff and supplies. Attitudes and perception of providers and clients about the new model needs to be determined also. It is also important to conduct a multicountry analysis to assess the claim of WHO knowing fully that WHO conducted the trial of this model in only four countries none of which is from sub-Saharan Africa

Digit preference in Nigerian censuses data of 1991 and 2006

Background: censuses in developing countries are prone to errors of age misreporting due to ignorance, low literacy levels and other social, economic and cultural factors. Ages are commonly rounded with great affinity for 0 or 5. This tendency to digit preference and/or avoidance results in age heaping or concentration of ages at certain digits. This study examined the extent of digit preference in the Nigerian census data of 1991 and 2006. Methods: this study utilized age data from the 1991 and 2006 Nigerian censuses reported in single years. The Whipple and Myers indices were used to determine the extent of digit preference. Results: both the 1991 and 2006 census data showed the expected pattern of errors, with Whipple and Myers indices being beyond acceptable levels. The Whipple index for 1991 and 2006 was 293 and 251 respectively, while the Myers index was 62.3 and 67.1 respectively. There was a strong preference for terminal digits 0 and 5, followed by 8 whereas terminal digits 1 and 9 were strongly avoided. Conclusions: the quality of age data in Nigerian census data is poor as a result of misreporting and no significant improvement or difference was observed between 1991 and 2006 censuses

Reproductive Health and Family Planning Services in Africa: Looking beyond Individual and Household Factors

Worldwide, there have been remarkable gains in the provision and utilization of reproductive health and FP services. However, in Africa, despite increasing availability, utilization of these services is less than 50%, even though there are wide variations among and within the countries across the continent. Articles from peer-reviewed journals, technical reports, Internet articles, grey literature (official government documents, technical reports, etc.) and Demographic and Health Survey (DHS) reports were used as resource materials. Manual search of reference list of selected articles was done for further relevant materials. We also used for comparative analysis, the online StatCompiler tool (https://www.statcompiler.com/en/) to extract data. Reproductive health and contraceptives have a lot of benefits to the individual, family and community. However, despite near universal knowledge and availability of reproductive health and FP services in Africa, utilization of these services is less than optimal. Several factors operating at individual, household and within the community influence utilization of services. These factors are the cause of poor maternal health and care that might hinder population health and the attainment of Sustainable Development Goals (SDGs). Interventions to promote and sustain utilization of services should target these factors at different levels depending upon relative role/s of these factors

Northern Nigeria Maternal, Newborn and Child Health Programme: Selected Analyses from Population-Based Baseline Survey

Maternal mortality in Northern Nigeria is among the highest in the world. To guide programme planning we interviewed 7,442 women in April and May 2009 in three northern states (Katsina, Yobe, and Zamfara) to understand patterns of antenatal care and delivery. Here, we present findings from a population-based survey conducted under the PRRINN-MNCH Programme to provide evidence-base programmatic interventions aimed at improving maternal and child health indicators. In the paper, we outline the health challenges facing northern Nigeria, describe the PRRINN-MNCH Programme, describe the baseline survey design, implementation, and subsequent data. We provide a series of maternal and child health indicators in order to address two key important policy issues: (1) the importance of visits to health care facilities to enable women get proper maternal care, and (2) the importance of having access to skilled personnel at birth. We further describe how these data can be used to develop appropriate strategies for integrated programmes to increase awareness of pregnancy and delivery complications and to reduce the barriers to assessing risk and accessing the facilities in a timely manner. Appropriate strategies and interventions are necessary to address the existing health challenges. To a large extent, these data also provide an opportunity to measure the impact of the programme in assisting Nigeria attain the health Millennium Development Goals of maternal and child health

Knowledge, determinants and use of modern contraceptives among married women in Sabon Gari Zaria, Northern Nigeria

Introduction: Improving reproductive health of young women in least developed countries requires access to safe and effective contraceptive methods. We conducted a study on knowledge, determinants and use of modern contraceptives among married women in Sabon Gari, Zaria-Northern Nigeria. Objective : The study aimed to assess contraceptive knowledge, sources of information, determinants and use of modern FP. Methods: This was a cross sectional descriptive and health facility-based study. Respondents were selected consecutively from the out-patient clinic register of Comprehensive Health Centre, ABUTH Sabon Gari, Zaria. A structured questionnaire was used to collect data. Results: Only 309 questionnaires were finally analyzed. Mean age of respondents was 32.8 +/9.6 years. Majority (78%) were Muslim, married and in monogamous union (72.2%). Knowledge of modern FP was almost universal 97.7% even though knowledge of two or more methods was 55.3%. Mean number of contraceptives known by respondents was 2. About 42.7% of respondents have ever used any contraceptive method. The Contraceptive Prevalence Rate (CPR) was 15.2% and the preferred FP choice among respondents was the injectable contraceptives (5.2%). Sources of information on FP were Nurse 42.1% and relatives/friends 19.7%. Significant determinants of FP current use among the respondents include the age, education, occupation, religion and choice of the respondents ( P < 0.05). Conclusions: FP use among study participants attending the centre is low despite good knowledge of modern contraception. Factors associated with contraceptive use should be used by all tiers of Government to organize sustained publicity awareness campaigns in order to improve acceptability and usage

RANDOMISED DOUBLE-BLIND PLACEBO-CONTROLLED STUDY OF FOLIC ACID ADJUNCT FOR 8 WEEKS IN HYPERHOMOCYSTEINAEMIC HYPERTENSIVE PATIENTS IN ZARIA, NIGERIA

Objectives: This study was aimed at determining the effect of folic acid adjunct therapy on homocysteine (HCY) and blood pressure (BP) levels in hypertensive subjects. Method: The study was a double blind placebo-controlled trial on 100 hypertensive patients randomised into 50 folate and 50 placebo groups, where the folate group had 5 mg folic acid daily for 8 weeks. Fasting plasma homocysteine, folate and blood pressure levels were determined at baseline, at 4 and at 8 weeks. The Mixed Model Repeated Measures analysis of variance was applied for data analysis. Results: Hyperhomocysteinaemia was found at baseline in the folate (21.3 ± 5.7 µmol/L) and placebo (21.6 ± 4.9 µmol/L) groups which did not differ statistically (p &gt; 0.05). Folic acid adjunct therapy, reduced homocysteine levels at 4 weeks by 2.0 µmol/L (9.2 %, p &lt; 0.05) and at 8 weeks by 1.2 µmol/L (5.6 %, p &lt; 0.05), with no significant (p &gt; 0.05) systolic and diastolic blood pressure lowering effect. High base-line folate levels were found in both folate (113.8 ± 51.2 ng/ml) and placebo groups (109.5 ± 51.4 ng/ml) with no statistically significant difference (p &gt; 0.05). Conclusion: Short-term daily folic acid supplementation over 8 weeks had a significant homocysteine reduction effect with no significant reduction in systolic and diastolic blood pressures of hypertensive subjects in Zaria, Nigeria. Hyperhomocysteinaemia could not be accounted for by suboptimal folate levels. Keywords: Hypertension, Homocysteine, Blood pressure, Folate, Placebo, Nigeria

Knowledge, sources of information, and risk factors for sexually transmitted infections among secondary school youth in Zaria, Northern Nigeria

Background: Sexually transmitted infections (STIs) are responsible for a variety of health problems especially among the youth who engage in risky sexual behavior. There are few studies that describe STIs among the youths in Northern Nigeria. The objective of the study was to assess knowledge of STIs and risk factors among secondary school youth. Materials and Methods: This was a cross‑sectional study in which structured, self‑administered questionnaire was used to collect data on socio‑demographics, knowledge on STIs, and risk factors. Three senior secondary schools were purposively selected for the study. Results: A total of 1765 youths aged 10‑30 years with mean age of 16.9 ± 2.0 years participated in the study. 1371 (77.7%) and 394 (22.3%) were respectively Muslim and Christian. Mean age at first sexual intercourse was 16.7 ± 2.0 years.A majority (67.6%) of them heard about STIs; sources of information of STIs were school lessons 23.6%, mass media 23.3%, and health magazines 19.2%, respectively. Generally, knowledge on STIs was good as 75.4% of respondents knew how the disease is transmitted. This knowledge was significantly associated with class of student, place of treatment, and religious teaching (χ2 = 9.6, P = 0.047, χ2 = 22.1, P = 0.035 and 42.6, P = 0.001, respectively). Mean knowledge score was 0.698 ± 0.01. A majority of respondents were engaged in risky sexual behavior as only 16.2% use condom as a preventive measure. Eleven percent reported ever having an STI in the past and majority (52.8%) go to government hospital for treatment of acquired STI. 56% of the youth had two or more boy/girl friends and 30% had sexual relationships. Conclusion: It was concluded that secondary school youth had good knowledge about STIs; however, the opposite is true when it comes to preventive practice (use of condom). Interventions such as periodic publicity awareness and school seminars focusing on STI preventions are needed to control the disease among the youth

Characteristics of COVID-19 cases and factors associated with their mortality in Katsina State, Nigeria, April-July 2020

Introduction: COVID-19 was first detected in Daura, Katsina State, Nigeria on 4 April 2020. We characterized the cases and outlined factors associated with mortality. Methods: We analysed the COVID-19 data downloaded from Surveillance Outbreak Response, Management and Analysis System between 4 April and 31 July 2020. We defined a case as any person with a positive SARS-CoV-2 test within that period. We described the cases in time, person, and place; calculated the crude and adjusted odds ratios and 95% confidence intervals for factors associated with mortality. Results: We analysed 744 confirmed cases (median age 35, range 1-90), 73% males and 24 deaths (Case fatality rate 3.2%, Attack rate 8.5/100,000). The outbreak affected 31 districts, started in week 14, peaked in week 26, and is ongoing. Highest proportion of cases in the age groups were 26.7% (184) in 30-39, 21.7% (153) in 20-29 years, and 18.3% (129) in 40-49 years. While the highest case fatality rates in the age groups were 35.7% in 70-79, 33.3% in 80-89 years, and 19.4% in 60-69 years. Factors associated with death were cough (AOR: 9.88, 95% CI: 1.29-75.79), age ≥60 years (AOR: 18.42, 95% CI: 7.48-45.38), and male sex (AOR: 4.4, 95% CI: 0.98-20.12). Conclusion: Male contacts below 40 years carried the burden of COVID-19. Also, persons 60 years and above, with cough have an increased risk of dying from COVID-19. Risk communication should advocate for use of preventive measures, protection of persons 60 years and above, and consideration of cough as a red-flag sign

Facilitators and barriers to seasonal malaria chemoprevention (SMC) uptake in Nigeria: a qualitative approach

BACKGROUND: SMC was adopted in Nigeria in 2014 and by 2021 was being implemented in 18 states, over four months between June and October by 143000 community drug distributors (CDDs) to a target population of 23million children. Further expansion of SMC is planned, extending to 21 states with four or five monthly cycles. In view of this massive scale-up, the National Malaria Elimination Programme undertook qualitative research in five states shortly after the 2021 campaign to understand community attitudes to SMC so that these perspectives inform future planning of SMC delivery in Nigeria. METHODS: In 20 wards representing urban and rural areas with low and high SMC coverage in five states, focus group discussions were held with caregivers, and in-depth interviews conducted with community leaders and community drug distributors. Interviews were also held with local government area and State malaria focal persons and at national level with the NMEP coordinator, and representatives of partners working on SMC in Nigeria. Interviews were recorded and transcribed, those in local languages translated into English, and transcripts analysed using NVivo software. RESULTS: In total, 84 focus groups and 106 interviews were completed. Malaria was seen as a major health concern, SMC was widely accepted as a key preventive measure, and community drug distributors (CDDs) were generally trusted. Caregivers preferred SMC delivered door-to-door to the fixed-point approach, because it allowed them to continue daily tasks, and allowed time for the CDD to answer questions. Barriers to SMC uptake included perceived side-effects of SMC drugs, a lack of understanding of the purpose of SMC, mistrust and suspicions that medicines provided free may be unsafe or ineffective, and local shortages of drugs. CONCLUSIONS: Recommendations from this study were shared with all community drug distributors and others involved in SMC campaigns during cascade training in 2022, including the need to strengthen communication about the safety and effectiveness of SMC, recruiting distributors from the local community, greater involvement of state and national level pharmacovigilance coordinators, and stricter adherence to the planned medicine allocations to avoid local shortages. The findings reinforce the importance of retaining door-to-door delivery of SMC