Project Summary: While 79 percent of Nigerian mothers who deliver in facilities receive postnatal care within 48 hours of delivery, only 16 percent of mothers who deliver outside facilities receive postnatal care within this period. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics recommend that unskilled birth attendants be involved in advocacy for skilled care use among mothers. This study explores postnatal care referral behavior by TBAs (Traditional Birth Attendants) in Nigeria, including the perceived factors that may deter or promote referrals to skilled health workers. We find that differences in TBA referral before, during, and after delivery appear to reflect the TBA’s understanding of the added value of skilled care for the client and the TBA, as well as the TBA’s perception of the implications of referral for her credibility as a maternal care provider among her clients. We also found that there are opportunities to engage TBA’s in routine postnatal care referrals of their clients to facilities in Nigeria by using incentives and promoting a cordial relationship between TBAs and skilled health workers. Thus, despite the potential negative consequences TBAs may face with postnatal care referrals, there are opportunities to promote these referrals using incentives and promoting a cordial relationship between TBAs and skilled health workers. The study was conducted in July 2016 in Ebonyi State, South-Eastern Nigeria, where about 1 in 2 mothers does not receive postnatal care within the first two days of childbirth. In addition, while 71 - 97 percent of mothers in other states in the South-Eastern region receive skilled birth attendance on average, coverage falls to 62 percent in Ebonyi State.

Data Abstract: This study collected qualitative data using focus group discussions (FGD) involving 28 female health workers, TBAs, and TBA delivery clients. The study conceptual framework drew on constructs in Fishbein and Ajzen’s theory of reasoned action onto which we mapped hypothesized determinants of postnatal care referrals described in the empirical literature. As part of a larger mixed methods study, the study team purposively selected 128 wards in Ebonyi State that had at least one primary health care facility with a health care provider offering maternal postnatal care. We identified these wards using the national facility census list and via consultations with officials in the State Ministry of Health. Each selected ward also had to have at least one TBA who lived and worked there. We recruited FGD participants from these wards. The recommended sample size for focus group discussions is 6 - 12 participants, as group interviews are difficult to manage above 12. The study team decided on FGD participant categories based on the key stakeholder groups involved in referrals for postnatal care. Thus, we purposively selected 10 TBAs, 10 TBA clients (mothers who had been delivered by TBAs), and 8 health care providers from communities that had primary health care facilities offering postnatal care services by a skilled provider and at least one resident TBA (we intended to interview 10 health care providers, 2 of whom arrived at the interview venue after the discussion was held). At recruitment, potential participants were informed that the study was aimed at understanding postnatal care practice in their communities. Health care providers were recruited face-to-face through a monthly meeting in the primary health care board in the state capital. TBAs were identified in partnership with health care providers, and recruited face-to-face in the 2 cases where they were based in the state capital. Recruitment over the phone was done for 8 TBAs who lived outside the state capital. We recruited TBA clients by asking recruited TBAs for the name of at least one past client, who was then contacted by the study team. Recruitment over the phone was done for 8 TBA clients who lived outside the state capital. TBA clients were required to be beyond 42 days after the culmination of their first pregnancy so that they would have had the opportunity to choose to attend at least one postnatal visit. TBA clients with multiple past pregnancies were therefore qualified to join the study as well. None of the recruited participants declined the invitation to the study. Discussions were held in a quiet, secluded location in the State Teaching Hospital.

We held one FGD with 8 health workers, another with 10 TBAs, and a final FGD with 10 TBA delivery clients (9 of whom came for the discussion with their newborns). All the participants were female. The focus groups lasted an average of 75 minutes (64 – 87 minutes). Most participants (39 percent) were between 30 and 39 years of age. A slightly lower proportion (36 percent) were between 20 and 29 years of age. Focus groups were conducted in either English or Igbo language depending on participant consensus. The discussions were audio-recorded with the consent of participants and facilitated using topic guides by an experienced qualitative researcher. The topics in the discussion guide were informed by the review of the empirical literature and study conceptual framework and differed by participant type. The topic guides for this study were developed in line with the study conceptual framework, which drew on constructs in Fishbein and Ajzen’s theory of reasoned action, to which we mapped hypothesized determinants of postnatal care referrals described in the empirical literature. In the discussion, we linked study themes to the study conceptual framework, to explain variation in traditional birth attendant referral behavior across the maternal continuum, from the antenatal to postnatal period. All focus group discussions were audio recorded and one of the members of the two-man research team took notes during discussions. The research team translated the audio-recordings in Igbo language into English language, and transcribed all the recordings verbatim in Microsoft Word. We will share the anonymized transcripts of audio recordings in English Language. The audio recordings, in both English and Igbo language, will not be shared as participant identities cannot be protected as agreed under the ethical review. We analyzed the transcribed data thematically, and linked themes to the study conceptual framework in the discussion to explain variation in TBA referral behavior across the maternal continuum, from the antenatal to postnatal period.

Researchers involved in the project: Adanna Chukwuma (Principal Investigator) Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, MA Conceptualized and designed the study, analyzed and interpreted the data, and drafted the manuscript. Chinyere Mbachu Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria Involved in analyzing and interpreting the data, drafting of the manuscript, and revision of intellectual content of the manuscript. Jessica Cohen Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, MA Involved in the design of the study, interpretation of the data, and revision of intellectual concept of the manuscript. Margaret McConnell Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, MA Involved in the design of the study, interpretation of the data, and revision of intellectual concept of the manuscript. Thomas Bossert Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, MA Involved in the design of the study, interpretation of the data, and revision of intellectual concept of the manuscript.