A model of community engagement in the prevention of maternal health complications in rural communities of Cross River State, Nigeria
Pregnancy-related poor maternal health and maternal death remain major problems in most Nigerian states including Cross River State. The acute impact of these problems is borne more heavily by rural communities where the majority of births take place at home unassisted or assisted by unskilled persons. These problems are due to a mixture of problem recognition and decision-making during obstetric emergencies leading to delayed actions. Every pregnancy faces risk, and prenatal screening cannot detect which pregnancy will develop complications. If the goal of reducing maternal morbidity/mortality is to be achieved, increasing the number of women receiving care from a skilled provider (doctor/nurse/midwife) during pregnancy, delivery, and post-delivery and prompt adequate care for obstetric complications has been identified as the single most important intervention. One of the strategies identified in many countries is engaging and working with individuals, families, and communities as partners to improve the quality of maternal healthcare. This strategy is thought to remove the barriers that dissuade women from using the services that are available, empowering the community members to increase their influence and control of maternal health, promote ownership and sustenance, as well as increase access to skilled care. The aim of the study: The overall aim of this PhD study was to develop a model of community engagement to facilitate the prevention of maternal health complications in the rural areas of Cross River State, Nigeria. To develop this model, the study specifically sought to: 1. Understand the current situation in Cross River State by exploring the knowledge gap of women of child-bearing age (pregnant and new mothers) regarding obstetric danger signs, birth preparedness and complication readiness, delivery practices of women, the action of family/community members, and the role of community-based maternal health initiatives, if any, in emergencies, as well as explore participants’ opinions on actions to be taken by the community to promote the utilisation of orthodox healthcare facilities by rural women of Cross River State (Phase 1). 2. Engage community members through a participatory approach (Photovoice) to highlight problems regarding pregnancy and birth practices, identify possible solutions, and make recommendations on communities’ roles in the prevention of maternal health complications (Phase 2). The older women of the study communities were also engaged to verify and validate the findings from phases 1 & 2 analyses. 3. Develop a model of community engagement to improve maternal health literacy by increasing knowledge on early detection of obstetric complications, birth preparedness, complication readiness, and improved access to skilled birth attendance (Phase 3). Methods: The study was conducted using a qualitative descriptive research approach that combined qualitative semi-structured interviews and focus group discussions within the Photovoice participatory approach. Purposive sampling was employed to select 20 participants, 10 each from the Idundu (Community A) and Anyanganse (Community B) rural communities of Akpabuyo Local Government Area of Cross River State, Nigeria. The participants comprised pregnant women and new mothers (babies aged 12 months and younger) who met the eligibility criteria. Data collection was by means of semi-structured interviews (Phase1), focused group discussions and Photovoice (Phase 2). Trustworthiness of the data was ensured by means of applying Guba’s model of credibility, transferability, and authenticity. The ethical principles of respect for human dignity, beneficence, confidentiality, and justice were applied throughout the study. The Citizenship Healthcare and Socio-Ecological Logic models were used to direct the study. Permission was obtained from participants for all the phases of the study while approval for the study was obtained from the Senate Higher Degrees Committee of the University of the Western Cape and the Cross River State Ministry of Health Ethical Committee. Data was analysed using Tesch’s method of content analysis. Based on the findings of Phases 1 & 2 of the study, themes emerged that were then validated by the older women in the study communities. The model was then developed by means of the four steps of the theory generation process. Step one was concept development that consisted of the identification, definition, validation, classification, and verification of the main and related concepts. Step two was model development consisting of the sub-steps, namely model guidelines and definitions. The communities’ stakeholders were engaged at this phase to verify and validate the concepts, as well as contribute to the drafting of the model guidelines and the definitions. Step three was a model description whereby the structure, definition, relation statements, and the process of the model were described. A visual application of the model that depicts the main concepts, the process, and the context was shown. Step four dealt with the development of guidelines for the operation of the model. A critical reflection of the model was done using Chinn and Kramer’s five criteria for model evaluation. Results: The study revealed that Idundu and Anyanganse’s rural women have limited knowledge of obstetric danger signs and very few of them acknowledged the importance of hospital delivery. They also exhibited poor understanding of what birth preparedness and complication readiness entailed. There was a high preference for traditional birth attendant care during pregnancy and delivery with their reasons being belief and trust in traditional birth attendants, a long standing tradition to deliver with them, assumptions that orthodox healthcare is expensive, poor attitude of healthcare providers towards women, unavailability of 24-hour services in healthcare facilities, fear of hospital procedures and operations, communal living in traditional birth attendant’s homes, spirituality in traditional birth attendant services, and the consideration of proximity to service points. These factors exacerbated the delays in seeking care and in referrals for skilled care in phases of emergency. The study also revealed that in the study communities, heavy household chores carried out by pregnant women is culturally accepted and seen as exercise to ease labour, there is lack of proper information regarding maternal and child health issues, men are sole decision-makers, they are ignorant of availability of free treatment in health centres, there is an ignorance regarding care of the new-born, and a lack of community structures to support women’s health. Based on the above findings, the women made the following suggestions towards finding a solution: improving maternal health literacy, increasing spirituality in service delivery, involving of husbands in antenatal care for proper information on maternal health issues, accessing community support through the use of community structures (town announcers, women groups, churches, etc.) with the purpose of emphasising facility delivery, constitution of influential groups to monitor the activities of pregnant women to ensure utilisation of skilled attendants, access to healthcare through free services and availability of providers, trust of health services, and traditional birth attendant training/traditional birth attendant facility collaboration. A total of eight concepts were identified from the concluding statements of steps 1 & 2, and used to develop the Maternal Health-Community Engagement Model (MH-CEM). These were: maternal health literacy, spirituality in healthcare, integrated traditional birth attendants’ role (value, training, and traditional birth attendants/hospital collaboration), trust in health services (by addressing previous experiences, attitude, and fear), improving access to healthcare, culturally acceptable care, husbands’ involvement in women’s health issues, and community support. These concepts formed the core components for the Maternal Health-Community Engagement Model which was developed as the main recommendation to address the core concepts. Central to this Model was the Community Engagement Group (CEG) which was established during the process of engaging the community stakeholders in validating the concepts and drawing up of the guidelines for the Model development. Conclusions and Recommendations: It is believed that the activities of the Community Engagement Group may bring about improved maternal health literacy, a process for working with traditional birth attendants through training and re-orienting them to be promoters of facility delivery when appropriate, and a model for involving husbands, and indeed the entire community, in maternal health issues. Limitations were identified and recommendations for nursing practice, education, and research concluded the study.