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Improving the Quality of Focused Antenatal Care as a Platform for the Control of Malaria in Pregnancy in Akwa Ibom State of Nigeria
by: Emmanuel Otolorin, Country Director, Jhpiego Nigeria; Bright Orji, Program Manager, Jhpiego Nigeria; Gbenga Ishola, Regional M&E Officer, Jhpiego Nigeria; William Brieger, Senior Malaria Specialist, Jhpiego-JHU
Results (continued)
Akwa Ibom State (%) 70.1 25.8 60 68.2 68.5 62.1 62.1 35.5 12.6

Background
Malaria is endemic
in Nigeria and is responsible for: 4,500 maternal deaths annually 63% of hospital admissions 70% of morbidity among pregnant Map of Nigeria women showing project state Akwa Ibom State 25% of infant mortality 30% of under-5 mortality
Katsina Zamfara Jigawa Yobe Kebbi Kano Kaduna Bauchi Gombe Niger Kwara
Federal Capital Territory

Quality of Antenatal Care (ANC) in Akwa Ibom State Is Sub-Optimal Components of ANC provided to pregnant women
Sokoto Borno

National average (%) 54.3 9.6 61.3 86.8 85.1 74.5 73.6 40.9 4.9

Took iron tablets/syrup during most recent pregnancy Took intestinal parasite drugs Informed about danger signs in pregnancy Weighed during most recent pregnancy Had blood pressure checked Had urine sample taken for analysis Had blood sample taken for tests Slept under insecticide-treated bed net (ITN) previous night Received two doses of sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy (IPTp)

Adamawa

Plateau

Nassarawa

Oyo

Osun

Ekiti

Taraba

Kogi

Ogun

Benue

Lagos

Ondo

Edo

Enugu Anambra Ebonyi

Delta

Cross Imo Abia Rivers Akwa Ibom

Rivers Bayelsa

Statistically more (87.7%) of the women from the control LGAs than women from the intervention LGAs (75.4%) received ANC from the local clinic (government health facility) (2=16.88; p<0.00001) during the baseline assessment. However, the situation was reversed during the endline assessment, as 85.9% of the women in the intervention arm received ANC services from the local clinics, while only 79.1% of women in the control arm did so (p=0.0036). A comparison of the intervention arms in the baseline and endline assessments also showed a statistically significant improvement in the endline over the baseline (p<0.0001). This implies that the implementation of the intervention pushed up the utilization of the local clinics for ANC services among pregnant women in the intervention arm. Reference: Exxon/Jhpiego Endline Report 2010

Methods
Project Approach

Results
Compliance with Set ANC Standards

The Jhpiego-ExxonMobil project was implemented

from 2007 to 2012. The project goal was to strengthen the delivery of malaria in pregnancy (MIP) services at 15 ANC clinics in four Local Government Areas (LGAs) of Akwa Ibom State. To reach this goal, Jhpiego used a two-pronged approach: Community-directed interventions to deliver MIP interventions; and Standards-Based Management and Recognition (SBM-R) to improve the quality of ANC services in project clinics.
Figure 1: Project concept and design based on the clinic-to-community continuum of care

During the life of the project, compliance with the

16 performance standards for ANC improved from a mean of 15.8% (range 619%) at baseline to 91% (range 8894%) at endline (see Figure 4). While only 5.8% of pregnant women received two doses of IPTp in the health facilities at baseline, compliance rose to 21.4% at endline. Compliance with ANC Performance Standards at Four Health Facilities
Figure 4: Baseline and follow-up performance scores at four project health facilities
100 90 80 70 60 50 40 30 20 10 0 Baseline Round 1 Round 2 Round 3 Round 4 Round 5 Ext. Verification

Examples of Causes of Persistent Gaps Across Health Facilities Lack of: Equipment to estimate hemoglobin (e.g., HemoCue blood analyzers) Midwife takes clients blood pressure at an Rapid diagnostic ANC clinic test kits for HIV and malaria Urinalysis test kits for albumin VDRL kits to determine syphilis status Illustrative Interventions to Bridge Performance Gaps Orientation of staff to focused ANC Procurement and distribution of HemoCue blood analyzers, VDRL and urinalysis test kits to facilities Procurement and deployment of microscopes and rapid diagnostic test kits for malaria Training of staff to use the test kits Identification, training and deployment of volunteers as community-directed distributors to distribute ITNs, provide IPTp medications and refer clients to ANC for other services

Clinic
MIP performance standards developed and implemented

Training Supervision Mobilization Commodities Referrals Records Feedback

Community
MIP skills and responsibilities implemented through community-directed interventions

Percent Score

All project inputs were focused on strengthening ANC as a platform for the control of MIP

Poly Clinic Eket

Idung Iniang H/C

Upenekang PHC

Mkpanak H/C

Jhpiego introduced

Figure 2: SBM-R framework

Percent of Pregnant Women Receiving

the SBM-R approach to Set Implement improve the quality of Standards Standards 1 2 focused ANC, including interventions for the control of MIP. Using 16 pre-existing set 4 3 Recognize Measure performance standards Achievements Progress for ANC, a baseline assessment was performed in four project health facilities, followed by gap analysis, identification and implementation of remedial interventions, and five quarterly followup assessments (see Figure 3).
Figure 3: Implementation cycle Desired performance Gap Actual performance Intervention identification and implementation Model Adapted from the International Society for Performance Improvement Cause analysis

Figure 5: ANC attendance at The proportion of women project and control sites who attended ANC 100 87.7 85.9 during their most recent 79.1 80 75.4 pregnancy remained largely 60 unchanged. 40 The survey showed that ANC attendance was not 20 adversely affected by 0 Pre Post taking IPTp to pregnant Intervention Control women at home. This is probably due to the fact that community-directed distributors were trained to refer pregnant women to the ANC clinic.
Percent

Challenges
Frequent transfer of trained staff from project sites Delayed or no replacement of retired staff Poor motivation of staff with delay or non-payment

of salaries and approved allowances Lack of antimalarial commodities (SP, ITNs), test kits and equipment for health care providers to function Poor funding of primary health care by LGAs, leading to limited or delayed implementation of identified solutions to quality improvement

ANC services received at project sites where generally better than at regional and national levels. Access to tetanus toxoid, folic acid and two doses of IPTp were significantly higher in the intervention areas compared to the national average.

Figure 6: Components of ANC provided in MIP project sites

80 70 60 50 40 30 20 10 0 TT2 Project Site Folic Acid South South Zone 18.2 20.4 13.2 65 63.6 45.3 68.5 54.3 65.3

Conclusion
The quality of ANC can be improved through the
systematic application of the relevant section of the national Performance Standards for Emergency Obstetric and Newborn Care. This lays the foundation for improved control of MIP. Identified performance gaps are analyzed and used to develop action plans in conjunction with facility managers and other stakeholders, leading to implementation of solutions that address the gaps. It is recommended that governments at all levels should use the operational tool for their oversight functions, to identify and bridge performance gaps and strengthen referral systems.

IPTp-2 National Average

This project was implemented through a grant from the ExxonMobil Foundation and Ellicott Dredges, LLC to Jhpiego, an affiliate of the Johns Hopkins University.