Photo by Lindsay Mgbor/Department for International Development, CC BY-SA 2.0
Nigeria is the second largest contributor to under-five and maternal mortality globally. A contributing factor, particularly in rural areas, is thought to be the shortage of skilled birth attendance; some estimates suggest that up to 50 per cent of rural health facilities do not have a midwife.
In response, in 2009 the Nigerian government created the Midwives Service Scheme (MSS), to address two critical roadblocks: the shortage of skilled providers, and poor access to basic emergency obstetric care in rural communities. The MSS set the ambitious goal of doubling the proportion of deliveries attended by skilled birth attendants and reducing maternal and infant mortality in target areas by 60 per cent by December 2015. The key feature of the MSS is the recruitment and deployment of newly qualified, unemployed and retired midwives to rural health clinics to ensure access to skilled care.
The MSS is a public sector initiative in collaboration with the three tiers of government. Under the scheme, the Federal government of Nigeria signed a Memorandum of Understanding with all the states of the federation and the Local Governments in which each was assigned roles and responsibilities.
This evaluation is part of the overarching Better Obstetrics in Rural Nigeria (BORN) study, which aims to evaluate the effectiveness of the MSS. To achieve this, the evaluation compared outcomes between households in the catchment areas of MSS clinics (n=208) and in the catchment of matched comparison clinics (n=208) in 12 states [publication forthcoming]. We focus here on the nested qualitative study that was conducted in three states, from different geopolitical zones, around nine clinics that appeared to be having differing success in terms of recruitment/retention and uptake of services.
The qualitative study aimed to capture an in-depth understanding of the views and experiences of the policy makers responsible for overseeing the scheme, the midwives employed by the scheme, women who have recently given birth (both service and non-service users) and the wider community in order to better understand the barriers and facilitators in the implementation of the MSS.
Interviews were undertaken from June 2014 and January 2015. Systematic and rigorous analysis was undertaken using a method based on the constant comparative approach, supported by QSR Nvivo software.
In total we undertook 77 interviews with policymakers at different administrative levels (n=17; 3 Federal, 5 State, 9 Local), MSS deployed midwives (n=17) and women who have recently given birth (n=43) as well as 9 focus groups with wider community members.
The midwives employed by MSS expressed a sense of satisfaction and fulfilment from their work and it was clear that they perceived several positives to the scheme such as improving the maternal health services available to women and having the opportunity to test their professional skill.
Communities, including mothers, could not always speak specifically about the scheme although they had developed patterns of use, attending more frequently for antenatal rather than delivery and postnatal services as a result of the midwives arrival. However, respondents highlighted several challenges related to the implementation and operation of the scheme, ranging from the lack of equipment supplies and drugs, significant delays to payment of midwives’ allowances and inadequate facilities and living accommodation.
Participants’ grievances were directed at local governments who were considered to not be fulfilling their role in the MOU. Among midwives there was a perceived lack of job security, and a number reported that they planned to leave.
Policymakers at different levels often pointed to the perceived failings of other levels of government, which was linked to an apparent lack of engagement with the scheme. For state and local governments this stemmed from the belief that they had been excluded from the scheme’s design and as such felt that the terms as outlined in the MOU had been ‘forced’ upon them.
The inability to engage all state and local governments presents a serious threat to the long-term sustainability of the scheme.
The MSS is an ambitious human resources project. Our research highlights a number of challenges arising from the design of the scheme and implementation which are likely to limit its success and sustainability. Engagement of different tiers of government and midwives involved in the scheme will be crucial in resolving these.
