Jhpiego’s Malaria in Pregnancy (MIP) project in Akwa Ibom State, Nigeria flagged off its community component in July.Â Prior to that primary health clinic (PHC) staff at 15 local government facilities had been trained in focused antenatal care, malaria in pregnancy and community directed intervention. These staff in turn recruited and trained 734 volunteer community directed distributors (CDDs) who represent 459 kindreds in the 87 communities surrounding the PHCs.
Field monitoring is underway to document the first month’s activities. This includes attending the monthly meetings that CDDs have with their nearby health facility staff and review of both CDD and ANC clinic registers. CDDs are expected to provide health education on MIP prevention, provide the first does of IPTp if appropriate and refer pregnant women to ANC clinic. Baseline assessments showed that women were not utilizing ANC at local government facilities, so Jhpiego has started working with staff on quality improvement so that referred women will want to use the services.
ANC attendance has increased. Review of the registers in three small clinics showed a total of 8 ANC clients in April, 7 in May and 2 in June. This rose to 44 in July and 25 for the first half of August for the three clinics combined. Before one starts to get excited, one must look at the work of CDDs in distributing sulfadoxine-pyrimethamine for IPTp.Â For example, at one of the large operational base clinics, 84 women attended ANC in July. Only 24 of 44 CDD/kindred records for July had been collected by the staff, but these showed that the CDDs had seen 670 pregnant women. A similar pattern emerged at all facilities.
CDDs were interviewed individually and during their group meetings. They said that it has been so long since women utilized the local government clinics that it was difficult to convince them to be referred.Â Some women preferred checking in with TBAs near the time of delivery, while others relied on their churches for prenatal supervision and delivery.Â There were concerns about poor state of the infrastructure. Many complained of fees for registration, cards and medicines (although IPTp is free). Nurses often turn back those who cannot pay instead of at least providing them the free services that exist.
While free services such as blood pressure monitoring and tetanus toxoid immunization are free, the various fees and charges can amount to US $4.50 or more assuming a woman makes up to four ANC visits. This may sound inexpensive, but for people living on the proverbial dollar a day, it is a major cash outlay.
Advocacy visits are underway to local government chairpersons and supervisory councilors for health to encourage them to make all aspects of ANC free and improve the health facilities.Â While the CDDs are starting to reach pregnant women earlier with IPTp, their job is not done until the women attend ANC and get the full range of services intended to protect their pregnancy.