Implementing Community-Maternal and Perinatal Death Surveillance and Response to identify and prevent maternal and perinatal mortality in Kaduna State, Nigeria: Results and lessons from a pilot study

Implementing Community-Maternal and Perinatal Death Surveillance and Response to identify and prevent maternal and perinatal mortality in Kaduna State, Nigeria: Results and lessons from a pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementing Community-Maternal and Perinatal Death Surveillance and Response to identify and prevent maternal and perinatal mortality in Kaduna State, Nigeria: Results and lessons from a pilot study Alice Tilton, Clara Ladi Ejembi, Moshood Salawu, Elkana Aliyu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3285937/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: There is low utilisation of antenatal care, health facility delivery, and post-natal care in Kaduna State, Nigeria, contributing to high maternal and perinatal mortality. Our research aimed to determine if community-Maternal and Perinatal Death Surveillance and Response, inclusive of verbal and social autopsies, increased antenatal care coverage (ANC), facility deliveries, and postnatal care coverage (PNC). Methods: Mixed methods were used to monitor and evaluate the project. Data sources included health facility summary data from January 2021 to December 2022, Key Informant Interviews (KIIs), and Focus Group Discussions (FGDs) with health care workers from local facilities and men and women from the two communities. Indicators analysed included ANC coverage, skilled birth attendance rate, PNC coverage and qualitative indicators linked to trust of healthcare workers, blame for adverse events, and adoption of remedies to modifiable causes of maternal and or perinatal deaths. Quantitative and qualitative analyses were done on Microsoft Excel. Results: Social autopsies were found to be acceptable and valued by community members. Actions developed may have had a lifesaving impact: maternity clinic run by an unskilled attendant was closed down, 24-hour free transportation for pregnant women provided by taxi drivers, and pre-emptive blood donations by community members to support emergency preparedness for childbirth. Qualitative data suggested that c-MPDSR led to increases in health facility attendance for antenatal care, improved quality of care, and increased trust between community members and health facility staff. Conclusions: c-MPDSR with verbal and social autopsies supports communities in Kaduna State to identify and discuss the causes of maternal and perinatal deaths and design actions that save lives and improve the health of women and newborns. Maternal death perinatal death community health health seeking behaviour verbal autopsy social autopsy primary healthcare Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Despite substantial reduction in global maternal and perinatal mortalities in the past two decades, the World Health Organization estimates that globally in 2020, 287,000 women died from causes related to pregnancy, childbirth, or puerperium ( 1 , 2 ). Nigeria is the leading contributor to this burden, accounting for a disproportionate 28.5% of the deaths, with 512 maternal deaths for every 100,000 live births ( 3 , 4 ). With a perinatal mortality rate of 34/1000 total births ( 5 ), Nigeria is second only to India in the absolute number of newborn deaths ( 6 ). Most of these maternal and perinatal mortalities are among underserved, poor and rural populations ( 3 ). As with other countries around the world, these mortalities are likely to have increased in Nigeria because of the impact of COVID-19, which led to interruptions and other challenges with accessing essential reproductive, maternal and child health services ( 7 , 8 ). Through the Sustainable Development Goal (SDGs), worldwide initiatives are intended to lower the global maternal mortality ratio to less than 70 per 100,000 live births and the neonatal mortality rate to less than 12 per 1000 live births and eliminate all preventable maternal and neonatal deaths ( 9 ). Nigeria is a signatory to the agenda, which is being pursued through various national policies and strategies including the National Health Policy ( 10 ), the National Strategic Development Plan II ( 11 ) and the Reproductive, Maternal, Child and Adolescent Health plus Nutrition Investment Case 2017–2030 ( 12 ).The country did not achieve the MDG targets and trends in both maternal and perinatal mortality reduction are significantly off what would be required to achieve SDG targets. From 2005 to 2015, the annual rate of maternal mortality reduction in Nigeria was 1.5%, this needs to increase to 15.1% during 2015–2030 ( 13 ). One of the reasons for poor maternal and perinatal health outcomes in Nigeria is the low use of antenatal and postnatal care, and institutional deliveries ( 14 , 15 ). Across Nigeria, 61% of women give birth at home without access to skilled attendants and life-saving emergency obstetric services that could significantly reduce maternal and perinatal mortalities ( 3 , 16 ). Aggregate maternal and child health indices in the country mask wide variations in coverage of key interventions and health outcomes. For example, the 2018 National Demographic and Health Survey (DHS) showed that the proportion of deliveries that took place at home was 84% in the North West Zone compared to 18% in the South East Zone ( 3 ). Maternal deaths that take place at home are not automatically captured in the national vital registration system, nor investigated or acted upon to avert similar deaths in future. The impact of home deliveries on maternal and perinatal mortality rates is perceived to be high and remains largely unknown. In 2013, the WHO issued guidelines for Maternal and Perinatal Death Surveillance (MPDSR) as a deliberate effort to curb maternal and perinatal mortality. "The goal of the MPDSR system is to ensure that every maternal and perinatal death provides useful lessons on how to prevent future cases by ensuring that every maternal and perinatal death is documented, investigated and the information generated used for actions to prevent similar occurrences in future” ( 17 ). Since 2015, the WHO and UNICEF have recommended the institutionalization of MPDSR in countries globally. In Nigeria, the National Council on Health adopted the national MPDSR guidelines in 2016 ( 18 ). However, community level data is severely limited in this system as deaths that occur outside of health facility settings are rarely (if at all) audited. Without strengthening the inclusion of data on deaths that occur outside of healthcare settings within national and sub-national systems, making significant impact in maternal and perinatal death reduction will remain a dream. Community Maternal and Perinatal Death Surveillance and Response (c-MPDSR) is an attempt to redress this gap. C-MPDSR is a nascent model that seeks to identify, document, and investigate all maternal and perinatal deaths irrespective of place of occurrence – home, on the road to the health facility, or at the health facility. Several pilots and studies have been conducted ( 19 – 21 ), though there remains no standard or best practice c-MPDSR approach. In Nigeria, in 2013–2014, the National Primary Health Care Development Agency attempted to include verbal autopsy as part of its Midwives Service Scheme. More recently, some development partners have tried to promote c-MPDSR in some states. Unfortunately, beyond documenting the medical causes of maternal and perinatal deaths through verbal autopsies, there has been little involvement of community members and findings have not been translated into actionable plans that include and work with communities to address the contributory causes of such deaths at community level. In addition to verbal autopsies, a key component of c-MPDSR are social autopsies. Social autopsies bring communities together to explore the modifiable root causes contributing to maternal and perinatal deaths. Through a process of reflection and interaction, community members identify modifiable social, cultural, and behavioural and health system-related factors contributing to the maternal and perinatal deaths, triggering development and implementation of community action plans to avert future deaths ( 22 – 24 ). Including only verbal autopsies and not social autopsies in c-MPDSR models limits the usefulness and effectiveness of the interventions to make a meaningful contribution to maternal and perinatal mortality reduction. One of the aims of this project was to generate evidence on the acceptability and effectiveness of c-MPDSR, especially the use of social autopsy and its effect on community norms, maternal health care-seeking behaviour, and trust between community members and healthcare providers. Methods Study Location The c-MPDSR model was implemented in two communities in Soba Local Government Area (LGA) in Kaduna State. Located in northwest Nigeria, Kaduna State had an estimated population of 9,735,051 in 2022, spread over 23 Local Government Areas. The poverty level in the state in 2022 was 52.6%, which is higher than the national average (25). The state has a total of 1,983 health facilities, 58% are government-owned and 85% are primary health care facilities at various levels of functionality ( 26 ). There is at least one functional government-owned primary health care facility in each of the 255 political wards in the state. There are also several privately-owned facilities operating at different levels of the health system, they make up a total of 41.6% of the total 1986 health facilities located in the state. Utilization of health facilities for deliveries is poor in the state; in 2022, only 31.4% of women delivered in health facilities and 58.6% delivered at home ( 5 ). The maternal mortality ratio in Kaduna State is estimated to be 1025/100,000 live births ( 27 ). These statistics hide wide variation within the state. In Soba LGA, just 3.2% of women in Soba LGA aged 15–49 years with a live birth in the two years preceding the 2020 survey gave birth in a health facility (1.7% in a public facility and 1.5% in a private facility) and 96.8% gave birth at home, including 34.1% who gave birth at home with no attendant ( 28 ). This LGA is in the northern part of the state and has an estimated population of 238,719 comprising a conservative Hausa and Fulani ethnic groups who are predominantly Moslem by religion and practice subsistence agriculture. Two settlements within the Soba LGA were purposively selected by Kaduna State Primary Health Care Development Agency (SPHCDA) for this c-MPDSR intervention – Soba, a peri-urban community, which is the headquarters of the LGA that has a population of 50,154 and Yakasai, a rural settlement with a population of 5,216 ( 26 ). Soba LGA has a total of 11 facilities made up of one focal Primary Healthcare Centre (PHC), 7 health clinics and 3 private primary health care facilities. Yakassai has one rural general hospital, one focal primary health care centre and 6 health clinics. Design of the c-MPDSR model The c-MPDSR model was co-designed with the Kaduna SPHCDA. The co-design process involved a 3-day workshop with state actors involved in the implementation of the state’s MPDSR system, Soba Local Government Health Department, the ward focal PHC representatives, and members from the Ward Development Committees (WDCs) of the two wards, in which both target communities are located, were selected for the implementation of c-MPDSR. The aim was to adapt c-MDPSR in a way that is inclusive, cost-effective, sustainable and fosters community participation from the outset. Following a literature review of different c-MPDSR models, our approach drew mainly from Bayley et al., community-linked maternal death review pilot in Malawi ( 21 ). The model designed from the meeting is shown in Fig. 1 . Figure 1 : The c-MPDSR Model co-designed with the Kaduna SPHCDA The Kaduna c-MPDSR model included the following key features: integration of social autopsy in addition to verbal autopsy; integration of c-MPDSR into the existing health system; and community-led implementation. Social autopsies are a fundamental feature of this c-MPDSR model. There is little guidance on how to conduct social autopsies and they are often conflated with verbal autopsies. In this model, social autopsies are a gathering during which community leaders guide community members to identify behaviours or barriers that result in maternal and perinatal deaths and collaboratively design solutions that support the use of skilled birth attendants (SBA) and antenatal care (ANC), as ways to reduce maternal and perinatal mortality. Integration within existing health system processes is essential for sustainability and cost-effectiveness. In this model, healthcare workers from the ward focal PHCs were trained to conduct the verbal autopsies and facilitate the social autopsies. Additionally, health system actors from LGA and state levels were included and kept up to date. LGA actors attended the social autopsies, helping to identify issues and design solutions that could also impact communities beyond those in which the deaths are discussed, enhancing the cost-effectiveness of the approach. Community leadership over the implementation of c-MPDSR was central to this model. In other c-MPDSR approaches promoted by development partners in the country, including in Kaduna State, the community MPDSR committee is constituted at the LGA level, and all decisions are taken at that level with little community participation. By contrast, in this c-MPDSR model, PHC healthcare workers and community residents were active members of the c-MPDSR committees. Other members of the committee included representatives from the Ward Development Committee, Village Heads, LGA Reproductive Health Coordinator, Community Engagement Focal Person, Traditional Birth Attendants, women leaders, youth leaders, and traditional and religious leaders. Training and mentoring were provided to the c-MPDSR committee members on how to conduct verbal and social autopsies that respect the dignity of the deceased and their family members as well as facilitate open discussion and identification of solutions. Key to this was ensuring social autopsies were a “no-name and no-blame” space and facilitating conversations in a respectful and non-accusatory manner. Furthermore, the c-MPDSR Committees selected well-known individuals, including volunteer community-based health workers in each community cluster to serve as community informants to report suspected maternal and perinatal deaths. Prior to the commencement of the c-MPDSR model in the two communities, as part of community entry activities, community dialogues were held with a broad range of community stakeholders that included local government officials, traditional and religious leaders, representatives of male and female groups, healthcare workers from public and private health facilities, traditional birth attendants and community-based organizations. Two key outcomes of the community dialogues were the unanimous endorsement to support the project and the contribution of the participants to the selection of the community informants. The c-MPDSR model process As shown in Fig. 1 , on hearing of a suspected maternal or perinatal death in their assigned area, the community informant triggered the c-MPDSR process by reporting such occurrence to the leadership of the c-MPDSR committee. For ease of function, the informants were expected to report the death of every woman of childbearing age or newborn less than 7 days of age. Within two days of any suspected maternal or perinatal death, representatives of the c-MPDSR committee paid a condolence visit to the family of the deceased. During the visit, they sought permission to conduct a verbal autopsy, which was then conducted by the trained local healthcare worker within a week of the death. The verbal autopsy comprised of a series of open-ended questions, sourced from the National MPDSR Guidelines, designed to establish the medical causes of the death and the social, behavioural, and health-systems-related factors that contribute to deaths using the three-delay model framework. The healthcare worker uses this information to confirm if the death was a maternal death or perinatal death. The report of the verbal autopsy was then presented to the c-MPDSR committee during their review meeting where it was analysed to determine immediate and contributory factors that led to the death. The same report was discussed at the ward focal PHC where representatives of the facility reflected on contributory health system-related factors and proposed solutions. To include a death in a social autopsy, the c-MPDSR committee sought consent from the bereaved family. If consent was given, the case would be anonymized and presented alongside others during the social autopsy. The plan was to conduct the social autopsies with between 50–60 community members, but after the initial autopsies, citing the benefits of the engagement, the leadership of the two communities requested the removal of any ceiling on participation. The social autopsies comprised anywhere between 50–200 participants, with the meetings held at a neutral community venue determined by the c-MPDSR committee. Participants at the social autopsies usually included the traditional and religious leaders of the communities, the health secretary of the local government and his/her team, family members of the deceased and representatives of various stakeholders in the community. The meetings were facilitated by members of the c-MPDSR committee. The social autopsies always started with an introductory discussion on causes and prevention of maternal and perinatal mortality using the 3-delay model, followed by a review of the action tracker on the proposed actions for maternal and perinatal mortality prevention from previous meetings. Case summaries of maternal and perinatal mortalities that had occurred in their communities from the last meeting were then presented and the facilitators guided the discussions to enable community members determine the contributory factors to the mortalities. Following this, participants were asked to suggest actions to avert similar occurrences in future; these formed the basis for the development of the community action plans. Each social autopsy was concluded with a health education session on birth preparedness and complication readiness and the importance of antenatal care and health facility delivery. Actions beyond what could be done at community level were escalated to higher levels by the Local Government Health Secretary and presented to the state officials during the periodic review meetings. The c-MPDSR committee held monthly meetings to review progress in implementation of the action plans. Study design and sample A mixed method study design was used to collect qualitative and quantitative data for assessing the acceptability of social autopsies and the effects of c-MPDSR on community norms, antenatal and postnatal care uptake and facility delivery, and trust between health workers and the community. Markers of trust included respect, assurance of treatment when needed, willingness to accept drawbacks (e.g., tolerate rudeness or expensive treatments), loyalty to the health facility staff, and perceived honesty, competency, and reliability ( 29 , 30 ). The study was completed over 10 months, between October 2021 to July 2022. Qualitative data were collected through Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). FGD were purposively sampled from primary health care workers in public and private health facilities, and adult men and women in the two communities. Separate male and female focus groups were constituted for each of the two communities while one FDG was held for health workers in each of the two communities at baseline (November 2021) and endline (July 2022). Eleven KIIs were held in March 2022 as part of a midterm assessment. A total of 131 persons made up of 33 health workers (approx. 80% women), 51 men and 37 women participated in FGDs and/or KIIs during the project’s implementation. Quantitative data was obtained from all public and private facilities in the two study communities providing antenatal and delivery services were included in the study, covering January 2021 to December 2022 to identify any effect of the intervention on uptake of services. Data collection Focus Group Discussions and Key Informant Interviews A trained moderator guided the discussions and interviews using discussion guides containing semi-structured questions, which were mostly conducted in the local Hausa language. All FGD and KII participants signed informed consent forms. No one under the age of 16 participated in the FGDs or KIIs. Health facility summary data Routine service data on antenatal and postnatal attendance and number of deliveries were extracted from all health facilities providing the services in the study sites for the period January 2021 to December 2022. Data management and analysis The FGDs were recorded, transcribed verbatim, and translated into English. All data were stored electronically on a secured laptop, with password protection. FGD data were analysed using Microsoft Excel using a Framework Approach ( 31 ). The thematic framework was developed from the transcripts and the FGD guides and data were coded into themes. Once all the transcripts were indexed with the same codes and themes, they were charted so that data within themes could be explored and relationships and patterns between themes and concepts could be identified. Health facility summary data were also analysed using Microsoft Excel. The key indicators were trends in uptake of ANC (at least 4 ANC and 8 ANC visits) and PNC (on day 1, day 2–3, day 4–7, and after 7 days) and deliveries in health facilities. Ethical Considerations Confidentiality, dignity, and respect were at the heart of this c-MPDSR model. Ethical approval was granted by the Kaduna State Ministry of Health, Health Research Ethical Committee and permission was sought from the Soba Local Government Health Authority Health Secretary and the community leaders of the two communities. Consent was also embedded in the delivery of the model: communities were aware that notifying community informants of a death was entirely voluntary; c-MDPSR committee members paid condolence visits ahead of asking permission to conduct a verbal autopsy; and consent was obtained from bereaved families to include anonymised cases as part of social autopsies, ensuring that no identifiable information about the deceased was presented during the sessions. Results Maternal and Perinatal death identification: During the study period, there were 19 suspected maternal deaths and 30 suspected perinatal deaths across both communities. Of the suspected deaths, 67% of maternal deaths and 85% of perinatal deaths were notified within 48 hours and verbal autopsies were carried out on all these deaths to confirm if they were maternal and perinatal deaths. This process confirmed 17 maternal deaths and 30 perinatal deaths that occurred in the communities between November 2021 to July 2022. Table 1 provides details from two example verbal autopsy reports. Table 1 Social autopsies of maternal and perinatal deaths: Ten social autopsies were conducted on a selection of the confirmed maternal and perinatal deaths – 6 in Soba community and 4 in Yakassai community. All the social autopsies were led by the respective Chairpersons of the c-MPDSR committee and local healthcare workers, with supportive supervision. The social autopsies were well-attended, with around 100-200 people attending each session, including religious leaders, women groups, TBAs, health facility staff, representatives of the bereaved families, and SPHCDA representatives such as the LGA Health Secretary, LGA Reproductive Health coordinator, LGA Monitoring and Evaluation Officer. The participation of these stakeholders was recognized by community members; in particular, several respondents in the midterm assessment of the programme noted the importance of the participation of the Sarki (the traditional leader): “ What impress me the most is seeing the Sarki (village head) and Liman (Muslim Religious Leader) were also contributing to the discussion. [It] really motivated me and made me stood firm and I was happy ” (midterm respondent 8, female community member, Soba). Those interviewed in the midterm assessment noted that during the social autopsies “ everyone was free to express themselves without any form of fear ” (midterm respondent 10, male community member, Yakassai) and “ there was nothing done that made us uncomfortable ” (midterm respondent 9, male community member, Soba). During the social autopsies, the two communities discussed socio-cultural factors that may have contributed to maternal and perinatal mortality cases and developed actions to avoid or reduce occurrences in the future. Facilitators used the 3 delays model to help frame the discussions and design of actions. Table 2 shows examples of the actions designed and taken by community members in response to maternal and perinatal deaths that occurred in their communities. Table 2 Health-seeking behaviour: i. Antenatal care attendance Respondents in the endline FGDs all agreed that ANC attendance had increased, and women are commencing ANC earlier as a result of the activities developed during the social autopsies and implemented by community members: “ We ourselves we can see changes in the health facility because compared to the number of women that used to come for antenatal before, the women have increased ” (Soba, HCW, 7) “ Anten atal care utilization has increased a lot and we are very pleased ” (Yakassai, HCW, 4) “ Initially, they will not come to ANC until maybe they are about to deliver. But so far, with the help of the project, they have started coming to ANC on time ” (HCW, Soba, 3) “ With the support from this organization, instead of commencing at 7 to 8 months, now it is 2,3 and even 4, they will start attending ” (Yakassai, HCW, 4) However, data collected from health facilities did not indicate an increase in ANC attendance (as shown in Figure 2), nor was there an increase in women commencing before 20 weeks of gestation. This raises questions on the accuracy of both data sources, discussed in the section below Reasons for not attending ANC included challenges affording transport to a facility, or fear of being requested to do additional scans that are not included in the free healthcare package and may also require visiting a facility further away, entailing more transport funds. “ The woman wants to go for ANC, but if there is no money for transport some will not be able to go especially if the place is far from the PHC ” (Soba, male, 7). Socio-cultural norms were also raised, with examples shared of them persisting as well as being overcome: “ There are some things that you inherit from your parents and ancestors that people are pract icing. Say for ANC, they will say no, rather they will soak some herbs (traditional medicine) ” (Soba, male, 8) “ Some women want to come [to ANC] but the men don’t (want them to) and truly the program has led to change in mindset ” (Soba, female, 5) ii. Health facility delivery Endline FGD respondents suggested that despite increases seen in ANC attendance, similar increases were not witnessed with respect to health facility deliveries. “ With the awareness campaign there has been positive change, the only thing now is convincing them to deliver their babies at the facility. This is the process we are working on, but they do access antenatal care ” (Soba, female, 2) “ T ruly the majority deliver at home, that is the truth. Even myself, I prefer to deliver in my room ” (Soba, female, 8) “ To be frank some women don’t usually visit the hospital only if they have a problem ” (Yakassai female 2) Health facility records reflected this by showing no increase in the number of women delivering in the health facilities (Figure 3). Reasons for not delivering in a health facility shared by the FGD respondents included socio-cultural beliefs that hold delivering at home is a sign of strength, lack of finances for consumables or transport, safety concerns because of the unstable security situation and fear of a female healthcare worker not being available, particularly at night Despite the lack of progress in the communities as a whole, several respondents shared examples of using an NURTW driver to take a pregnant woman to a health facility, and of TBAs bringing women to a health facility rather than treating them at home. This suggests that the referral pathway from home to the health facility may have been strengthened and utilized more so than previously: “ I am a witness as well because my daughter was taken to a TBA and because of her condition, one of the union drivers was called upon and immediately he came and took us to the facility ” (Soba female 10) “ Since this program came truly, most TBAs see the situation the woman is in, she will tell the woman to follow her to the hospital. Some will tell you they don’t have money, the TBA will persuade her that it won’t be impossible, let us go ” (Yakassai, female, 10) “ I was there when we went to pick the woman up. I called on the driver and we took her to the hospital to save her life. The husband was thankful, if she was at home she would have died ” (Soba, female, 6) iii. Post-natal care attendance Health facility records showed a continuing increase in the number of women attending PNC between January 2021 to December 2022, with most of the increase seen in those attending on Day 1 (Figure 4). some FGD respondents reported that attendance had increased, particularly amongst women who had delivered at home. “ Truly they do come for post-natal even when they deliver at home. Before this project they don’t come for post-natal, they will say they deliver safely and why will they come to the facility ” (Soba, female, 4) “ Even when they deliver at home, they come to the health facility on the same day so they and their newborn can be examined ” (Yakassai, HCW, 2) Other respondents disagreed and cited resistance from husbands and mothers-in-law towards PNC. “ Especially a mother-in-law, she might stop her from going for post-natal care, she will say that the daughter in law already deliver safely why will she want to visit the facility ” (Soba, female 11) “ Some men also feel that when the wife delivers safely there is no need for that and he will feel she is being extravagant with money ” (Soba, female, 4) T rust between communities and health facilities: FGD respondents were asked various questions surrounding markers of trust (29,30). The study found that trust in the competency of healthcare workers was strengthened as a result of increased friendliness of healthcare workers: “ In the past the health workers are disregarded because of their ill attitude to people but now with the programme, health workers attend to them competently ” (Soba, female, 3) “ Now the community people think well of the health workers that once a patient comes there is no doubt they will be treated well ” (Soba, male, 9) Healthcare workers themselves noted the importance of shifting their own behaviour to improve utilization of the health facilities: “ Even we the health workers, we had our own problems; a woman might want to come to the facility, but she will say the health worker is troublesome, I will not go. Now, we have made them like family, like friends, whatever, they want, we do for them, so we have made progress “(Soba, HCW, 10) “ We have recorded progress, many women come because the health workers are friendlier and more receptive. Now the attendance is higher ” (Yakassai, HCW, 6) Healthcare workers also shared examples of how they had improved their competency as a result of the c-MPDSR programme. “ Now, you don’t want it to be said that someone died because of you, whether baby or mother, so you do everything according to the process, it is unlike before ” (Yakassai HCW 3) “ During the social autopsy, we were told to desist from using oxytocin to augment a normal labor. Now, we know that the problem we encounter of women bleeding results from giving these things before labor, you see we have made progress ” (Soba, HCW, 6) “Instead of doing trial and error, you refer (the patient), so that there is no problem resulting from your action. Because of this, we are experiencing improvements ” (Yakassai, HCW, 4) Blame for adverse events was mostly aimed at healthcare workers or attributed to God’s will in the baseline assessment. By the endline assessment, there was growing recognition that not attending or delaying access to healthcare contributes to such deaths: “ There are changes, after the social autopsy they came and said they didn’t know that that is how things are and they now understand that some of the things that happen is as a result of their negligence, they use to think it was our lapses, but they have realized that it is their negligence ” (Yakassai, HCW, 4) “ Because in the past, they did not know that if they are- if a woman dies from childbirth, they just attribute it to fate- that is what God willed, it was her time. Now, they have began to understand that their negligence also contributes to this ” (Soba HCW 8) Husbands were most often blamed for a family’s delay to seek appropriate care (or ‘negligence’). Consequences include not being able to marry another woman. “ Many people in the community when a husband refused to take his wife to the hospital will conclude he killed the wife ” (Soba, male, 11) “ If he allows the woman to die and he didn’t do anything, then when he decides to take another wife, they will not want to give him ” (Soba, female, 2) Discussion Our c-MPDSR model has shown that communities in Kaduna State can identify and discuss causes of maternal and perinatal deaths and come up with actions that can save lives and improve the health of women and newborns. Whilst we cannot confirm that health seeking behaviour increased as a result of the intervention, FGD respondents almost unanimously agreed that ANC had increased, but were far less insistent about an increase in health facility deliveries. It would be strange for a social desirability bias to apply only to ANC and not health facility delivery. This raises questions on the accuracy of health facility records. When meeting with Kaduna SPHCDA to disseminate and discuss the data collected through the endline assessment, it was raised that data quality at health facilities may decrease as they become busier. This would suggest that the slight decline seen in the number of women attending ANC in Figure 2, may actually be a result of poorer record keeping as there were more women attending. This is speculation though and requires further interrogation. Similarly, whilst we cannot report reductions in maternal and perinatal deaths, the actions that the communities are implementing and the increased awareness of and agency to solve challenges that lead to deaths, will likely lead to significant reductions in maternal and perinatal mortality over time. In fact, health facility data suggests a decrease in the number stillbirths reported following the start of the project (Figure 5). Given the noted data quality issues, this requires further investigation, but could be a result of the reports from healthcare workers and community members that quality of care had improved, including timely referrals. The study also found that social autopsies have been widely accepted by community members, many of whom noted the value of congregating, discussing issues, and creating solutions together. Our c-MPDSR model understood that socio-cultural and religious norms substantially influence agency and decision-making in Kaduna State, affecting health-seeking behaviour and practices that can result in negative outcomes for women and newborns. Because of this, we sought the support and participation of community leaders such as village heads, WDC members, and religious leaders in the model. Their involvement in the model’s activities was critical to the communities’ buy-in and participation in social autopsies, helping to start shifting socio-cultural and religious norms and practices that can contribute to negative health outcomes for women and newborns. In particular, it is possible the discussions have helped women to raise issues that they felt unable to voice individually at household level but felt comfortable to raise as part of a collective of women. We have since trained c-MDPSR committees in how to encourage design of gender transformative actions during the social autopsies to ensure the programme contributes more concretely towards gender equality. Whilst social autopsies are valued by community members and effective in supporting communities to address causes of maternal and perinatal death at community level, they are resource intensive. C-MPDSR committee members require considerable training and supportive supervision before they are able to independently facilitate effective social autopsies. Kaduna SPHCDA was engaged from the outset and was committed to scaling up the model across the state. This commitment remains, however, limited domestic resources have so far prevented this. Instead, the state is working with other implementing partners to scale-up c-MPDSR through their existing programmes. Despite its cost, c-MPDSR offers a way for health systems to count maternal and perinatal deaths more accurately and provide tailored responses to help reduce such deaths. Not only this, but communities’ benefit both from being involved in the process of c-MPDSR through increased awareness, agency, and collaboration to solve problems that lead to deaths as well as through the actions that they themselves design and implement to reduce deaths. Communities are often overlooked in health systems or seen simply as users; in Soba LGA we have shown that through c-MPDSR, communities can and should be active agents. Their participation will be key if Nigeria is to accelerate its reduction of maternal and perinatal mortality and have any hope of achieving its SDG goals. Limitations Our study had several limitations. Namely, our reliance on purposively sampled FGD participants, potential social desirability bias in their responses, and reported poor quality of health facility summary records. Whilst we took measures to reduce the impact of these limitations (for instance, well-trained enumerators and using health facility data to assess trends rather than absolute numbers), it is unclear if and to what extent they affected the results. Additionally, the short timeframe of the project’s implementation and long-term investment that behaviour change requires meant that it was unlikely clear increases in health facility attendance would be identified. Abbreviations ANC Antenatal care c-MPDSR community-Maternal Perinatal Death Surveillance and Response DHS Demographic and Health Survey FGD Focus Group Discussion HCW Healthcare worker KII Key Informant Interview LGA Local Government Authority MDG Millennium Development Goal MPDSR Maternal Perinatal Death Surveillance and Response PHC Primary Health Centre PNC Post-natal care PRHI Population and Reproductive Health Initiative SBA Skilled birth attendance SDG Sustainable Development Goal SPHCDA State Primary Health Care Development Agency TBA Traditional birth attendant UNICEF United Nations Children's Fund WDC Ward Development Committee WHO World Health Organisation Declarations Ethics approval and consent to participate : All FGD and KII participants signed informed consent forms. The study received ethical approval from Kaduna State Ministry of Health, Health Research Ethical Committee and permission was sought from the Soba Local Government Health Authority Health Secretary and the community leaders of the two communities. Consent for publication : Not Applicable (NA) Availability of data and materials : All transcripts are available? Data was collected under the proviso that it would remain confidential, as such is not shareable outside of the research team. Research tools and training materials can be accessed here: https://www.mamaye.org/index.php/gpg/community-mpdsr-c-mpdsr-tools Competing interests : No competing interests. Funding : This project was made possible with support from the Evidence for Action – MamaYe programme, which is funded by the Bill & Melinda Gates Foundation and delivered by Options Consultancy Services. Authors' contributions : Alice Tilton: designed and wrote the study protocols, research tools, analysed data, and wrote majority of the manuscript. Clara Ejembi: provided oversight for the project’s design, implementation. and data collection and contributed to writing and reviewing the manuscript. Moshood Salawu: managed implementation and quality assurance of the project and research study and inputted to the manuscript. Elkana Aliyu: managed implementation of the project and research study and inputted to the manuscript. Oladapo Shittu: provided oversight for the project’s design and implementation and reviewed the manuscript. Punshak Wattle: supported implementation of the project and research study. Shade Olumeyin: supported implementation of the project and research study. Khadijah Abdulkarim: supported implementation of the project and research study. Acknowledgements: Population and Reproductive Health Initiative (PRHI) who provided on-the-ground support to implement the project and research study. Kaduna State PHCDA, Soba LGA, the C-MPDSR committee members, and community members residing in Soba and Yakassai for their engagement, guidance, and time committed to the project. References Nasir N, Aderoba AK, Ariana P. Scoping review of maternal and newborn health interventions and programmes in Nigeria. BMJ Open. 2022;12(2):1–11. Hug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet [Internet]. 2021;398(10302):772–85. http://dx.doi.org/10.1016/S0140-6736(21)01112-0 . National Population Commission (NPC) [Nigeria], ICF. Nigeria Demographic Health Survey 2018 [Internet]. The DHS Program ICF Rockville, Maryland, USA. 2019. p. 748. Available from: https://dhsprogram.com/publications/publication-fr359-dhs-final-reports.cfm . WHO, UNFPA, WORLD BANK, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]. World Health Organisation. Geneva., Trends in maternal mortality 2000 to 2020: estimates by WHO, ; 2023. Available from: https://www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/ . National Bureau of Statistics (NBS)., United Nations Children Fund. Multiple Indicator Cluster Survey 2021, Survey Findings Report. 2022;(August). WHO. Newborn Mortality [Internet]. Who. 2022. p. 0–2. Available from: https://www.who.int/news-room/fact-sheets/detail/levels-and-trends-in-child-mortality-report-2021%0Ahttps://www.unicef.org/ghana/REALLY_SIMPLE_STATS_-_Issue_1(1).pdf . Shapira G, Ahmed T, Drouard SHP, Amor Fernandez P, Kandpal E, Nzelu C, et al. Disruptions in maternal and child health service utilization during COVID-19: Analysis from eight sub-Saharan African countries. Health Policy Plan. 2021;36(7):1140–51. Ahmed T, Roberton T, Vergeer P, Hansen PM, Peters MA, Ofosu AA, et al. Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data. PLoS Med. 2022;19(8):1–20. United Nation. Social Development for Sustainable Development | DISD [Internet]. United Nation. 2015. Available from: https://www.un.org/development/desa/dspd/2030agenda-sdgs.html . Federal Government of Nigeria. National Health Policy 2016–2022. 2016. Federal Government of Nigeria. National Strategic Health Development Plan II: Ensuring healthy lives and promoting the wellbeing of Nigerian populace at all ages. 2018;1–136. Federal Ministry of Health Nigeira. Investment Case for Reproductive, Maternal, Newborn, Child, and Adolescent Health 2017–2030. 2016. p. 1–56. McArthur JW, Rasmussen K, Yamey G. How many lives are at stake? Assessing 2030 sustainable development goal trajectories for maternal and child health. BMJ [Internet]. 2018;360(February):1–9. http://dx.doi.org/doi:10.1136/bmj.k373 . Adewuyi EO, Khanal V, Zhao Y, David L, Bamidele OD, Auta A. Home childbirth among young mothers aged 15–24 years in Nigeria: A national population-based cross-sectional study. BMJ Open. 2019;9(9). Adewuyi EO, Zhao Y, Auta A, Lamichhane R. Prevalence and factors associated with non-utilization of healthcare facility for childbirth in rural and urban Nigeria: Analysis of a national population-based survey. Scand J Public Health. 2017;45(6):675–82. Fapohunda BM, Orobaton NG. When Women Deliver with No One Present in Nigeria: Who, What, Where and So What? PLoS ONE. 2013;8(7). World Health Organization. Maternal death surveillance and response: Technical information for action to prevent maternal deaths. 2013. Federal Ministry of Health. National Guidelines for Maternal Perinatal Death Surveillance and Response. 2015. Thomas LM, D’Ambruoso L, Balabanova D. Verbal autopsy in health policy and systems: A literature review. Vol. 3, BMJ Global Health. 2018. p. 1–10. Prata N, Gerdts C, Gessessew A. An innovative approach to measuring maternal mortality at the community leve in low-resource settings using mid-level providers. NIH Public. 2013;20(39):196–204. Bayley O, Chapota H, Kainja E, Phiri T, Gondwe C, King C, et al. Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: A pilot study in rural Malawi. BMJ Open. 2015;5(4):1–10. Mahato PK, Waithaka E, van Teijlingen E, Pant PR, Biswas A. Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries. WHO South-East Asia J public Heal. 2018;7(1):24–8. Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: A comprehensive literature review to examine the concept and the development of the method. Popul Health Metr. 2011;9:1–13. Moyer CA, Johnson C, Kaselitz E, Aborigo R. Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature. Glob Health Action [Internet]. 2017;10(1):1–15. https://doi.org/10.1080/16549716.2017.1413917 . World Bank. A Better Future for All Nigerians: 2022 Poverty Assessment. 2022. Kaduna State Government. Kaduna State Public Health Emergency Preparedness and Response Plan (draft). 2023. Kaduna State Government. Kaduna State Strategic Health Development Plan II. 2018. Kaduna State Bureau of Statistics. Kaduna State General Household Survey Report. 2020. Petschonek S, Burlison J, Cross C, Martin K, Laver J, Landis RS, et al. Development of the just culture assessment tool: Measuring the perceptions of health-care professionals in hospitals. J Patient Saf. 2013;9(4):190–7. Gopichandran V, Chetlapalli SK. Dimensions and Determinants of Trust in Health Care in Resource Poor Settings - A Qualitative Exploration. PLoS ONE. 2013;8(7). Gale NK, Heath G, Cameron E, Sabina R, Redwood S. Using the Framework Method for the Analysis of Qualitative Dyadic Data in Health Research. BMC Med Res Methodol. 2013;31. Footnotes In this study, poverty was measured using a consumption aggregate that was converted to per capita terms. The national poverty line was defined as 137,430 naira per person per year; this equates to roughly 1.93 USD 2011 PPP per person per day. Tables Table 1: Example verbal autopsy reports conducted and compiled by the respective c-MPDSR committees. Verbal autopsy report for m aternal and perinatal death, Soba community Date of death 18/01/2022 Date of reporting 20/01/2022 Date of Verbal Autopsy 26/01/2022 Date of Social Autopsy 07/02/2022 Narrative summary A mother (30 years old) passed on after delivery of a stillbirth, her pregnancy was up to term. She had 8 pregnancies but only 2 children alive. Her first 5 deliveries were normal deliveries with no complication. During her 6th pregnancy, she developed some complication and had a caesarean section to deliver a stillbirth. The health worker informed her that her womb had been affected and advised her on birth spacing. Unfortunately, she got pregnant in less than 2 years, and she had a normal delivery of a stillbirth. In less than 2 years, she got pregnant again and this pregnancy came with a lot of complications. She started attending ANC in a health clinic very close to her house at 8 weeks. She was ill throughout the pregnancy, suffering low strength, stomach pains, fever, headache amongst other symptoms. During her pregnancy, she did 10 scans. About two weeks before her demise, premature rupture of membranes meant she was losing liquid. One day before her demise, she felt very ill and returned to the health clinic where she receives ANC. The health worker assessed her and prescribed some drugs which she bought and drank, the health worker also referred her to a higher facility. That night, she passed two stools full of blood. The next morning, she proceeded to a private health clinic. The health worker examined her and told her the baby had passed on. He asked her to go elsewhere that he could not manage her case. She proceeded to another private health clinic. The health workers attempted to induce labour, when she discovered that the drip being passed was to induce her, she removed it and refused induction. Labour progressed and she delivered a stillbirth. This delivery was followed by excessive bleeding, she lost a lot of blood and required transfusion. Unfortunately, there was no blood nor available donor. While they were making arrangements for donor, she passed on. According to her mother she spent only about two hours in the last health facility before her demise. Her hospital cards were not made available during the verbal autopsy. Verbal autopsy report for perinatal death, Yakassai community Date of death 14/03/2022 Date of reporting 15/03/2022 Date of Verbal Autopsy 18/04/2022 Date of Social Autopsy 25/05/2022 Narrative summary A 28-year-old mother of 6 children with no evidence of antenatal care, lost her baby about an hour after she was born. Mother never attended antenatal and never took any form of medication or traditional medicine in the course of her pregnancy. She started labor at about 6am in the morning and delivered a female baby at about 2pm in the afternoon. The baby was born weak and didn't cry. Mother and baby were not taken to the hospital. According to the mother, the baby was not given any medication neither traditional nor modern medicines. Soon after being born, the baby’s color changed, and she started to breathe very fast until she suddenly stopped breathing around 3pm. Table 2: Actions taken by community members between November 2021- July 2022, presented in line with the 3 Delays Model Delay Actions Delay 1: Deciding to seek appropriate medical help for an obstetric emergency Healthcare workers (in particular, Community Health Extension Workers and Junior Community Health Extension Workers), and religious, traditional and women leaders conducted awareness raising and sensitization of community members on the importance of health facility utilization, ANC attendance, health facility delivery, and dangers of patronizing untrained persons. Husbands and grooms-to-be were instructed by the WDC and Village Head to give their standing consent for women to attend ANC and health facilities for delivery, even when they are not present. In Soba community, grooms-to-be must sign a form confirming this, which includes results of genotype testing to determine blood groups and potential for blood donorship if needed. This form must then be presented to religious leaders before marriage. TBAs were ordered to stop transfusing blood and community members were encouraged to report such practices to the WDC. The WDC also held a meeting with all private practitioners and the LGA Reproductive Health coordinator and various community mobilization groups (c-MPDSR community informants, Voluntary Community Mobilizers, Community Oriented Resource Persons, Nigeria Urban Reproductive Health Initiative mobilizers). During the meeting, the WDC educated all participants on danger signs, emphasized the need for referrals, the importance of sensitization and mobilization of pregnant women for ANC. The private practitioners admitted that they engaged in many wrong practices and committed to stopping going forward. Since this meeting, no further cases have been reported. WDC and health secretary raised awareness about the available health insurance schemes, most of which cover all maternity services, including scans and consumables. The Basic Contributory Healthcare Provision Fund was introduced to participants during a social autopsy, and they were encouraged to get their National Identity Management Commission cards as it is a condition for enrolment into the programme. Delay 2: Reaching an appropriate obstetric facility National Union of Road Traffic Workers (NURTW) agreed to transport pregnant women to health facilities for free at any time of day or night. The contact details of these drivers have been posted in the health facility, the Sarki’s palace, and distributed to c-MPDSR committee members, religious leaders, and village heads. Delay 3: Receiving adequate care when a facility is reached Members of a local Community Based Organisation found out their blood types and committed to donating blood regularly as well as being available in cases of emergency. Health facilities have adapted their rotas to ensure that there is always a female healthcare worker available, including on each night shift, and healthcare workers were reminded that they must attend their shifts. Healthcare workers were reminded that no community member is to pay for services relating to ANC and delivery, pregnant women will only be required to provide consumables (e.g., syringe and needles, detergents) to be used directly for them when the health facility is out of supply. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3285937","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":232839770,"identity":"04bb8069-2c3e-4cec-a66f-e4e9b85a4aed","order_by":0,"name":"Alice 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SPHCDA\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3285937/v1/b915f92b5aaa142bd9fd3808.png"},{"id":43500148,"identity":"814d1dab-d51b-4b13-9bfd-5daad184b66c","added_by":"auto","created_at":"2023-09-21 17:43:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65822,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of women with 4 and 8 ANC visits to health facilities in Soba and Yakassai communities between January 2021 and December 2022.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3285937/v1/ef7d6c56bea3c2107c7ff74f.png"},{"id":43500149,"identity":"0c534300-ae5d-4272-a472-bf43bbebba5e","added_by":"auto","created_at":"2023-09-21 17:43:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":54380,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of women delivering in health facilities in Soba and Yakassai communities between January 2021 and December 2022.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3285937/v1/ad112ccc5b99831f2cbc5db9.png"},{"id":43501187,"identity":"50ea29c2-7b4d-4f27-b43d-443b445fdded","added_by":"auto","created_at":"2023-09-21 17:51:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":65350,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of women PNC in health facilities in Soba and Yakassai communities between January 2021 and December 2022.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3285937/v1/3fa1f3fa2f85cd6344567494.png"},{"id":43501641,"identity":"71abd0c0-d8cf-462f-afc1-ea8df9cabcd8","added_by":"auto","created_at":"2023-09-21 17:59:15","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":57079,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of stillbirths in health facilities in Soba and Yakassai communities between January 2021 and December 2022.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3285937/v1/ec2b71e11e56a1e61ffd20b4.png"},{"id":61666395,"identity":"745e03e0-e088-4ba0-8374-42a0021b145f","added_by":"auto","created_at":"2024-08-02 16:14:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1575719,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3285937/v1/c26a5007-a8da-40fb-b3ae-1a6fbb88eab0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing Community-Maternal and Perinatal Death Surveillance and Response to identify and prevent maternal and perinatal mortality in Kaduna State, Nigeria: Results and lessons from a pilot study","fulltext":[{"header":"Background","content":"\u003cp\u003eDespite substantial reduction in global maternal and perinatal mortalities in the past two decades, the World Health Organization estimates that globally in 2020, 287,000 women died from causes related to pregnancy, childbirth, or puerperium (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Nigeria is the leading contributor to this burden, accounting for a disproportionate 28.5% of the deaths, with 512 maternal deaths for every 100,000 live births (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). With a perinatal mortality rate of 34/1000 total births (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), Nigeria is second only to India in the absolute number of newborn deaths (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Most of these maternal and perinatal mortalities are among underserved, poor and rural populations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As with other countries around the world, these mortalities are likely to have increased in Nigeria because of the impact of COVID-19, which led to interruptions and other challenges with accessing essential reproductive, maternal and child health services (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThrough the Sustainable Development Goal (SDGs), worldwide initiatives are intended to lower the global maternal mortality ratio to less than 70 per 100,000 live births and the neonatal mortality rate to less than 12 per 1000 live births and eliminate all preventable maternal and neonatal deaths (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Nigeria is a signatory to the agenda, which is being pursued through various national policies and strategies including the National Health Policy (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), the National Strategic Development Plan II (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and the Reproductive, Maternal, Child and Adolescent Health plus Nutrition Investment Case 2017\u0026ndash;2030 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).The country did not achieve the MDG targets and trends in both maternal and perinatal mortality reduction are significantly off what would be required to achieve SDG targets. From 2005 to 2015, the annual rate of maternal mortality reduction in Nigeria was 1.5%, this needs to increase to 15.1% during 2015\u0026ndash;2030 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the reasons for poor maternal and perinatal health outcomes in Nigeria is the low use of antenatal and postnatal care, and institutional deliveries (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Across Nigeria, 61% of women give birth at home without access to skilled attendants and life-saving emergency obstetric services that could significantly reduce maternal and perinatal mortalities (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Aggregate maternal and child health indices in the country mask wide variations in coverage of key interventions and health outcomes. For example, the 2018 National Demographic and Health Survey (DHS) showed that the proportion of deliveries that took place at home was 84% in the North West Zone compared to 18% in the South East Zone (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Maternal deaths that take place at home are not automatically captured in the national vital registration system, nor investigated or acted upon to avert similar deaths in future. The impact of home deliveries on maternal and perinatal mortality rates is perceived to be high and remains largely unknown.\u003c/p\u003e \u003cp\u003e In 2013, the WHO issued guidelines for Maternal and Perinatal Death Surveillance (MPDSR) as a deliberate effort to curb maternal and perinatal mortality. \"The goal of the MPDSR system is to ensure that every maternal and perinatal death provides useful lessons on how to prevent future cases by ensuring that every maternal and perinatal death is documented, investigated and the information generated used for actions to prevent similar occurrences in future\u0026rdquo; (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Since 2015, the WHO and UNICEF have recommended the institutionalization of MPDSR in countries globally. In Nigeria, the National Council on Health adopted the national MPDSR guidelines in 2016 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, community level data is severely limited in this system as deaths that occur outside of health facility settings are rarely (if at all) audited. Without strengthening the inclusion of data on deaths that occur outside of healthcare settings within national and sub-national systems, making significant impact in maternal and perinatal death reduction will remain a dream. Community Maternal and Perinatal Death Surveillance and Response (c-MPDSR) is an attempt to redress this gap.\u003c/p\u003e \u003cp\u003eC-MPDSR is a nascent model that seeks to identify, document, and investigate all maternal and perinatal deaths irrespective of place of occurrence \u0026ndash; home, on the road to the health facility, or at the health facility. Several pilots and studies have been conducted (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), though there remains no standard or best practice c-MPDSR approach.\u003c/p\u003e \u003cp\u003eIn Nigeria, in 2013\u0026ndash;2014, the National Primary Health Care Development Agency attempted to include verbal autopsy as part of its Midwives Service Scheme. More recently, some development partners have tried to promote c-MPDSR in some states. Unfortunately, beyond documenting the medical causes of maternal and perinatal deaths through verbal autopsies, there has been little involvement of community members and findings have not been translated into actionable plans that include and work with communities to address the contributory causes of such deaths at community level. In addition to verbal autopsies, a key component of c-MPDSR are social autopsies. Social autopsies bring communities together to explore the modifiable root causes contributing to maternal and perinatal deaths. Through a process of reflection and interaction, community members identify modifiable social, cultural, and behavioural and health system-related factors contributing to the maternal and perinatal deaths, triggering development and implementation of community action plans to avert future deaths (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Including only verbal autopsies and not social autopsies in c-MPDSR models limits the usefulness and effectiveness of the interventions to make a meaningful contribution to maternal and perinatal mortality reduction.\u003c/p\u003e \u003cp\u003eOne of the aims of this project was to generate evidence on the acceptability and effectiveness of c-MPDSR, especially the use of social autopsy and its effect on community norms, maternal health care-seeking behaviour, and trust between community members and healthcare providers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Location\u003c/h2\u003e \u003cp\u003eThe c-MPDSR model was implemented in two communities in Soba Local Government Area (LGA) in Kaduna State. Located in northwest Nigeria, Kaduna State had an estimated population of 9,735,051 in 2022, spread over 23 Local Government Areas. The poverty level in the state in 2022 was 52.6%, which is higher than the national average\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e (25). The state has a total of 1,983 health facilities, 58% are government-owned and 85% are primary health care facilities at various levels of functionality (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). There is at least one functional government-owned primary health care facility in each of the 255 political wards in the state. There are also several privately-owned facilities operating at different levels of the health system, they make up a total of 41.6% of the total 1986 health facilities located in the state. Utilization of health facilities for deliveries is poor in the state; in 2022, only 31.4% of women delivered in health facilities and 58.6% delivered at home (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The maternal mortality ratio in Kaduna State is estimated to be 1025/100,000 live births (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). These statistics hide wide variation within the state. In Soba LGA, just 3.2% of women in Soba LGA aged 15\u0026ndash;49 years with a live birth in the two years preceding the 2020 survey gave birth in a health facility (1.7% in a public facility and 1.5% in a private facility) and 96.8% gave birth at home, including 34.1% who gave birth at home with no attendant (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This LGA is in the northern part of the state and has an estimated population of 238,719 comprising a conservative Hausa and Fulani ethnic groups who are predominantly Moslem by religion and practice subsistence agriculture.\u003c/p\u003e \u003cp\u003eTwo settlements within the Soba LGA were purposively selected by Kaduna State Primary Health Care Development Agency (SPHCDA) for this c-MPDSR intervention \u0026ndash; Soba, a peri-urban community, which is the headquarters of the LGA that has a population of 50,154 and Yakasai, a rural settlement with a population of 5,216 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Soba LGA has a total of 11 facilities made up of one focal Primary Healthcare Centre (PHC), 7 health clinics and 3 private primary health care facilities. Yakassai has one rural general hospital, one focal primary health care centre and 6 health clinics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDesign of the c-MPDSR model\u003c/h2\u003e \u003cp\u003eThe c-MPDSR model was co-designed with the Kaduna SPHCDA. The co-design process involved a 3-day workshop with state actors involved in the implementation of the state\u0026rsquo;s MPDSR system, Soba Local Government Health Department, the ward focal PHC representatives, and members from the Ward Development Committees (WDCs) of the two wards, in which both target communities are located, were selected for the implementation of c-MPDSR. The aim was to adapt c-MDPSR in a way that is inclusive, cost-effective, sustainable and fosters community participation from the outset. Following a literature review of different c-MPDSR models, our approach drew mainly from Bayley et al., community-linked maternal death review pilot in Malawi (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The model designed from the meeting is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cem\u003eThe c-MPDSR Model co-designed with the Kaduna SPHCDA\u003c/em\u003e\u003c/p\u003e \u003cp\u003e The Kaduna c-MPDSR model included the following key features: integration of social autopsy in addition to verbal autopsy; integration of c-MPDSR into the existing health system; and community-led implementation.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSocial autopsies\u003c/b\u003e are a fundamental feature of this c-MPDSR model. There is little guidance on how to conduct social autopsies and they are often conflated with verbal autopsies. In this model, social autopsies are a gathering during which community leaders guide community members to identify behaviours or barriers that result in maternal and perinatal deaths and collaboratively design solutions that support the use of skilled birth attendants (SBA) and antenatal care (ANC), as ways to reduce maternal and perinatal mortality.\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntegration within existing health system processes\u003c/b\u003e is essential for sustainability and cost-effectiveness. In this model, healthcare workers from the ward focal PHCs were trained to conduct the verbal autopsies and facilitate the social autopsies. Additionally, health system actors from LGA and state levels were included and kept up to date. LGA actors attended the social autopsies, helping to identify issues and design solutions that could also impact communities beyond those in which the deaths are discussed, enhancing the cost-effectiveness of the approach.\u003c/p\u003e \u003cp\u003e\u003cb\u003eCommunity leadership\u003c/b\u003e over the implementation of c-MPDSR was central to this model. In other c-MPDSR approaches promoted by development partners in the country, including in Kaduna State, the community MPDSR committee is constituted at the LGA level, and all decisions are taken at that level with little community participation. By contrast, in this c-MPDSR model, PHC healthcare workers and community residents were active members of the c-MPDSR committees. Other members of the committee included representatives from the Ward Development Committee, Village Heads, LGA Reproductive Health Coordinator, Community Engagement Focal Person, Traditional Birth Attendants, women leaders, youth leaders, and traditional and religious leaders. Training and mentoring were provided to the c-MPDSR committee members on how to conduct verbal and social autopsies that respect the dignity of the deceased and their family members as well as facilitate open discussion and identification of solutions. Key to this was ensuring social autopsies were a \u0026ldquo;no-name and no-blame\u0026rdquo; space and facilitating conversations in a respectful and non-accusatory manner. Furthermore, the c-MPDSR Committees selected well-known individuals, including volunteer community-based health workers in each community cluster to serve as community informants to report suspected maternal and perinatal deaths.\u003c/p\u003e \u003cp\u003ePrior to the commencement of the c-MPDSR model in the two communities, as part of community entry activities, community dialogues were held with a broad range of community stakeholders that included local government officials, traditional and religious leaders, representatives of male and female groups, healthcare workers from public and private health facilities, traditional birth attendants and community-based organizations. Two key outcomes of the community dialogues were the unanimous endorsement to support the project and the contribution of the participants to the selection of the community informants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eThe c-MPDSR model process\u003c/h2\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, on hearing of a suspected maternal or perinatal death in their assigned area, the community informant triggered the c-MPDSR process by reporting such occurrence to the leadership of the c-MPDSR committee. For ease of function, the informants were expected to report the death of every woman of childbearing age or newborn less than 7 days of age. Within two days of any suspected maternal or perinatal death, representatives of the c-MPDSR committee paid a condolence visit to the family of the deceased. During the visit, they sought permission to conduct a verbal autopsy, which was then conducted by the trained local healthcare worker within a week of the death. The verbal autopsy comprised of a series of open-ended questions, sourced from the National MPDSR Guidelines, designed to establish the medical causes of the death and the social, behavioural, and health-systems-related factors that contribute to deaths using the three-delay model framework. The healthcare worker uses this information to confirm if the death was a maternal death or perinatal death. The report of the verbal autopsy was then presented to the c-MPDSR committee during their review meeting where it was analysed to determine immediate and contributory factors that led to the death. The same report was discussed at the ward focal PHC where representatives of the facility reflected on contributory health system-related factors and proposed solutions.\u003c/p\u003e \u003cp\u003eTo include a death in a social autopsy, the c-MPDSR committee sought consent from the bereaved family. If consent was given, the case would be anonymized and presented alongside others during the social autopsy. The plan was to conduct the social autopsies with between 50\u0026ndash;60 community members, but after the initial autopsies, citing the benefits of the engagement, the leadership of the two communities requested the removal of any ceiling on participation. The social autopsies comprised anywhere between 50\u0026ndash;200 participants, with the meetings held at a neutral community venue determined by the c-MPDSR committee. Participants at the social autopsies usually included the traditional and religious leaders of the communities, the health secretary of the local government and his/her team, family members of the deceased and representatives of various stakeholders in the community. The meetings were facilitated by members of the c-MPDSR committee.\u003c/p\u003e \u003cp\u003e The social autopsies always started with an introductory discussion on causes and prevention of maternal and perinatal mortality using the 3-delay model, followed by a review of the action tracker on the proposed actions for maternal and perinatal mortality prevention from previous meetings. Case summaries of maternal and perinatal mortalities that had occurred in their communities from the last meeting were then presented and the facilitators guided the discussions to enable community members determine the contributory factors to the mortalities. Following this, participants were asked to suggest actions to avert similar occurrences in future; these formed the basis for the development of the community action plans. Each social autopsy was concluded with a health education session on birth preparedness and complication readiness and the importance of antenatal care and health facility delivery. Actions beyond what could be done at community level were escalated to higher levels by the Local Government Health Secretary and presented to the state officials during the periodic review meetings. The c-MPDSR committee held monthly meetings to review progress in implementation of the action plans.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sample\u003c/h2\u003e \u003cp\u003e A mixed method study design was used to collect qualitative and quantitative data for assessing the acceptability of social autopsies and the effects of c-MPDSR on community norms, antenatal and postnatal care uptake and facility delivery, and trust between health workers and the community. Markers of trust included respect, assurance of treatment when needed, willingness to accept drawbacks (e.g., tolerate rudeness or expensive treatments), loyalty to the health facility staff, and perceived honesty, competency, and reliability (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The study was completed over 10 months, between October 2021 to July 2022.\u003c/p\u003e \u003cp\u003eQualitative data were collected through Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). FGD were purposively sampled from primary health care workers in public and private health facilities, and adult men and women in the two communities. Separate male and female focus groups were constituted for each of the two communities while one FDG was held for health workers in each of the two communities at baseline (November 2021) and endline (July 2022). Eleven KIIs were held in March 2022 as part of a midterm assessment. A total of 131 persons made up of 33 health workers (approx. 80% women), 51 men and 37 women participated in FGDs and/or KIIs during the project\u0026rsquo;s implementation.\u003c/p\u003e \u003cp\u003e Quantitative data was obtained from all public and private facilities in the two study communities providing antenatal and delivery services were included in the study, covering January 2021 to December 2022 to identify any effect of the intervention on uptake of services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eFocus Group Discussions and Key Informant Interviews\u003c/strong\u003e \u003cp\u003e A trained moderator guided the discussions and interviews using discussion guides containing semi-structured questions, which were mostly conducted in the local Hausa language. All FGD and KII participants signed informed consent forms. No one under the age of 16 participated in the FGDs or KIIs.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealth facility summary data\u003c/strong\u003e \u003cp\u003eRoutine service data on antenatal and postnatal attendance and number of deliveries were extracted from all health facilities providing the services in the study sites for the period January 2021 to December 2022.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData management and analysis\u003c/h2\u003e \u003cp\u003eThe FGDs were recorded, transcribed verbatim, and translated into English. All data were stored electronically on a secured laptop, with password protection. FGD data were analysed using Microsoft Excel using a Framework Approach (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The thematic framework was developed from the transcripts and the FGD guides and data were coded into themes. Once all the transcripts were indexed with the same codes and themes, they were charted so that data within themes could be explored and relationships and patterns between themes and concepts could be identified.\u003c/p\u003e \u003cp\u003eHealth facility summary data were also analysed using Microsoft Excel. The key indicators were trends in uptake of ANC (at least 4 ANC and 8 ANC visits) and PNC (on day 1, day 2\u0026ndash;3, day 4\u0026ndash;7, and after 7 days) and deliveries in health facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eConfidentiality, dignity, and respect were at the heart of this c-MPDSR model. Ethical approval was granted by the Kaduna State Ministry of Health, Health Research Ethical Committee and permission was sought from the Soba Local Government Health Authority Health Secretary and the community leaders of the two communities. Consent was also embedded in the delivery of the model: communities were aware that notifying community informants of a death was entirely voluntary; c-MDPSR committee members paid condolence visits ahead of asking permission to conduct a verbal autopsy; and consent was obtained from bereaved families to include anonymised cases as part of social autopsies, ensuring that no identifiable information about the deceased was presented during the sessions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eMaternal and Perinatal death identification:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, there were 19 suspected maternal deaths and 30 suspected perinatal deaths across both communities. Of the suspected deaths, 67% of maternal deaths and 85% of perinatal deaths were notified within 48 hours and verbal autopsies were carried out on all these deaths to confirm if they were maternal and perinatal deaths. This process confirmed 17 maternal deaths and 30 perinatal deaths that occurred in the communities between November 2021 to July 2022. Table 1 provides details from two example verbal autopsy reports.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSocial autopsies of maternal and perinatal deaths:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTen social autopsies were conducted on a selection of the confirmed maternal and perinatal deaths \u0026ndash; 6 in Soba community and 4 in Yakassai community. All the social autopsies were led by the respective Chairpersons of the c-MPDSR committee and local healthcare workers, with supportive supervision. The social autopsies were well-attended, with around 100-200 people attending each session, including religious leaders, women groups, TBAs, health facility staff, representatives of the bereaved families, and SPHCDA representatives such as the LGA Health Secretary, LGA Reproductive Health coordinator, LGA Monitoring and Evaluation Officer. \u0026nbsp;The participation of these stakeholders was recognized by community members; in particular, several respondents in the midterm assessment of the programme noted the importance of the participation of the Sarki (the traditional leader):\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWhat impress me the most is seeing the Sarki (village head) and Liman (Muslim Religious Leader) were also contributing to the discussion. [It] really motivated me and made me stood firm and I was happy\u003c/em\u003e\u0026rdquo; (midterm\u0026nbsp;respondent\u0026nbsp;8, female community member, Soba).\u003c/p\u003e\n\u003cp\u003eThose interviewed in the midterm assessment noted that during the social autopsies \u0026ldquo;\u003cem\u003eeveryone was free to express themselves without any form of fear\u003c/em\u003e\u0026rdquo; (midterm respondent 10, male community member, Yakassai) and \u0026ldquo;\u003cem\u003ethere was nothing done that made us uncomfortable\u003c/em\u003e\u0026rdquo; (midterm respondent 9, male community member, Soba).\u003c/p\u003e\n\u003cp\u003eDuring the social autopsies, the two communities discussed socio-cultural factors that may have contributed to maternal and perinatal mortality cases and developed actions to avoid or reduce occurrences in the future. Facilitators used the 3 delays model to help frame the discussions and design of actions. Table 2 shows examples of the actions designed and taken by community members in response to maternal and perinatal deaths that occurred in their communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHealth-seeking behaviour:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ei. Antenatal care attendance\u003c/p\u003e\n\u003cp\u003eRespondents in the endline FGDs all agreed that ANC attendance had increased, and women are commencing ANC earlier as a result of the activities developed during the social autopsies and implemented by community members:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWe ourselves we can see changes in the health facility because\u0026nbsp;\u003c/em\u003e\u003cem\u003ecompared to the number of women that used to come for antenatal before, the women have increased\u003c/em\u003e\u0026rdquo; (Soba, HCW, 7)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAnten\u003c/em\u003e\u003cem\u003eatal care utilization has increased a lot and we are very pleased\u003c/em\u003e\u0026rdquo; (Yakassai, HCW, 4)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eInitially, they will not come to ANC until maybe they are about to deliver. But so far, with the help of the project, they have started coming to ANC on time\u003c/em\u003e\u0026rdquo; (HCW, Soba, 3)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWith the support from this organization, instead of commencing at 7 to 8 months, now it is 2,3 and even 4, they will start attending\u003c/em\u003e\u0026rdquo; (Yakassai, HCW, 4)\u003c/p\u003e\n\u003cp\u003eHowever, data collected from health facilities did not indicate an increase in ANC attendance (as shown in Figure 2), nor was there an increase in women commencing before 20 weeks of gestation. This raises questions on the accuracy of both data sources, discussed in the section below\u003c/p\u003e\n\u003cp\u003eReasons for not attending ANC included challenges affording transport to a facility, or fear of being requested to do additional scans that are not included in the free healthcare package and may also require visiting a facility further away, entailing more transport funds.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe woman wants to go for ANC, but if there is no money for transport some will not be able to go especially if the place is far from the PHC\u003c/em\u003e\u0026rdquo; (Soba, male, 7).\u003c/p\u003e\n\u003cp\u003eSocio-cultural norms were also raised, with examples shared of them persisting as well as being overcome:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThere are some things that you inherit from your parents and ancestors that people are pract\u003c/em\u003e\u003cem\u003eicing. Say for ANC, they will say no, rather they will soak some herbs (traditional medicine)\u003c/em\u003e\u0026rdquo; (Soba, male, 8)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSome women want to come\u003c/em\u003e [to ANC] \u003cem\u003ebut the men don\u0026rsquo;t (want them to) and truly the program has led to change in\u003c/em\u003e \u003cem\u003emindset\u003c/em\u003e\u0026rdquo; (Soba, female, 5)\u003c/p\u003e\n\u003cp\u003eii. Health facility delivery\u003c/p\u003e\n\u003cp\u003eEndline FGD respondents suggested that despite increases seen in ANC attendance, similar increases were not witnessed with respect to health facility deliveries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWith the awareness campaign there has been positive change, the only thing now is convincing them to deliver their babies at\u003c/em\u003e\u003cem\u003e\u0026nbsp;the facility. This is the process we are working on, but they do access antenatal care\u003c/em\u003e\u0026rdquo; (Soba, female, 2)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eT\u003c/em\u003e\u003cem\u003eruly the majority deliver at home, that is the truth. Even myself, I prefer to deliver in my room\u003c/em\u003e\u0026rdquo; (Soba, female, 8)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eTo be frank some women don\u0026rsquo;t usually visit the hospital only if they have a problem\u003c/em\u003e\u0026rdquo; (Yakassai female 2)\u003c/p\u003e\n\u003cp\u003eHealth facility records reflected this by showing no increase in the number of women delivering in the health facilities (Figure 3).\u003c/p\u003e\n\u003cp\u003eReasons for not delivering in a health facility shared by the FGD respondents included socio-cultural beliefs that hold delivering at home is a sign of strength, lack of finances for consumables or transport, safety concerns because of the unstable security situation and fear of a female healthcare worker not being available, particularly at night\u003c/p\u003e\n\u003cp\u003eDespite the lack of progress in the communities as a whole, several respondents shared examples of using an\u0026nbsp;NURTW driver to take a pregnant woman to a health facility, and of TBAs bringing women to a health facility rather than treating them at home. This suggests that\u0026nbsp;the referral pathway from home to the health facility may have been strengthened and utilized more so than previously:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI am a witness as well because my daughter was taken to a TBA and because of her condition, one of the union drivers was called upon and immediately he came and took us to the facility\u003c/em\u003e\u0026rdquo; (Soba female 10)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSince this program came truly, most TBAs see the situation the woman is in, she will tell the woman to follow her to the hospital. Some will tell you they don\u0026rsquo;t have money, the TBA will persuade her that it won\u0026rsquo;t be impossible, let us go\u003c/em\u003e\u0026rdquo; (Yakassai, female, 10)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI was there when we went to pick the woman up. I called on the driver and we took her to the hospital to save her life. The husband was thankful, if she was at home she would have died\u003c/em\u003e\u0026rdquo; (Soba, female, 6)\u003c/p\u003e\n\u003cp\u003eiii. Post-natal care attendance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealth facility records showed a continuing increase in the number of women attending PNC between January 2021 to December 2022, with most of the increase seen in those attending on Day 1 (Figure 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003esome FGD respondents reported that attendance had increased, particularly amongst women who had delivered at home.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eTruly they do come for post-natal even when they deliver at home. Before this project they don\u0026rsquo;t come for post-natal, they will say they deliver safely and why will they come to the facility\u003c/em\u003e\u0026rdquo; (Soba, female, 4)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eEven when they deliver at home, they come to the health facility on the same day so they and their newborn can be examined\u003c/em\u003e\u0026rdquo; (Yakassai, HCW, 2)\u003c/p\u003e\n\u003cp\u003eOther respondents disagreed and cited resistance from husbands and mothers-in-law towards PNC.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eEspecially a mother-in-law, she might stop her from going for post-natal care, she will say that the daughter in law already deliver safely why will she want to visit the facility\u003c/em\u003e\u0026rdquo; (Soba, female 11)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSome men also feel that when the wife delivers safely there is no need for that and he will feel she is being extravagant with money\u003c/em\u003e\u0026rdquo; (Soba, female, 4)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eT\u003c/em\u003e\u003cem\u003erust between communities and health facilities: \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFGD respondents were asked various questions surrounding markers of trust\u0026nbsp;(29,30). The study found that trust in the competency of healthcare workers was strengthened as a result of increased friendliness of healthcare workers:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIn the past the health workers are disregarded because of their ill attitude to people but now with the programme, health workers attend to them competently\u003c/em\u003e\u0026rdquo; (Soba, female, 3)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eNow the community people think well of the health workers that once a patient comes there is no doubt they will be treated well\u003c/em\u003e\u0026rdquo; (Soba, male, 9)\u003c/p\u003e\n\u003cp\u003eHealthcare workers themselves noted the importance of shifting their own behaviour to improve utilization of the health facilities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eEven we the health workers, we had our own problems; a woman might want to come to the facility, but she will say the health worker is troublesome, I will not go. Now, we have made them like family, like friends, whatever, they want, we do for them, so we have made progress\u003c/em\u003e \u0026ldquo;(Soba, HCW, 10)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWe have recorded progress, many women come because the health workers are friendlier and more receptive. Now the attendance is higher\u003c/em\u003e\u0026rdquo; (Yakassai, HCW, 6)\u003c/p\u003e\n\u003cp\u003eHealthcare workers also shared examples of how they had improved their competency as a result of the c-MPDSR programme.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eNow, you don\u0026rsquo;t\u0026nbsp;\u003c/em\u003e\u003cem\u003ewant it to be said that someone died because of you, whether baby or mother, so you do everything according to the process, it is unlike before\u003c/em\u003e\u0026rdquo; (Yakassai HCW 3)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eDuring the social autopsy, we were told to desist from using oxytocin to augment a normal labor. Now, we know that the problem we encounter of women bleeding results from giving these things before labor, you see we have made progress\u003c/em\u003e\u0026rdquo; (Soba, HCW, 6)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Instead of doing trial and error, you refer (the patient), so that there is no problem resulting from your action. Because of this, we are experiencing improvements\u003c/em\u003e\u0026rdquo; (Yakassai, HCW, 4)\u003c/p\u003e\n\u003cp\u003eBlame for adverse events was mostly aimed at healthcare workers or attributed to God\u0026rsquo;s will in the baseline assessment. By the endline assessment, there was growing recognition that not attending or delaying access to healthcare contributes to such deaths: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThere are changes, after the social autopsy they came and said they didn\u0026rsquo;t know that that is how things are and they now understand that some of the things that happen is as a result of their negligence, they use to think it was our lapses, but they have realized that it is their negligence\u003c/em\u003e\u0026rdquo; (Yakassai, HCW, 4)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eBecause in the past, they did not know that if they are- if a woman dies from childbirth, they just attribute it to fate- that is what God willed, it was her time. Now, they have began to understand that their negligence also contributes to this\u003c/em\u003e\u0026rdquo; (Soba HCW 8)\u003c/p\u003e\n\u003cp\u003eHusbands were most often blamed for a family\u0026rsquo;s delay to seek appropriate care (or \u0026lsquo;negligence\u0026rsquo;). Consequences include not being able to marry another woman.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMany people in the community when a husband refused to take his wife to the hospital will conclude he killed the wife\u003c/em\u003e\u0026rdquo; (Soba, male, 11)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIf he allows the woman to die and he didn\u0026rsquo;t do anything, then when he decides to take another wife, they will not want to give him\u003c/em\u003e\u0026rdquo; (Soba, female, 2)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur c-MPDSR model has shown that communities in Kaduna State can identify and discuss causes of maternal and perinatal deaths and come up with actions that can save lives and improve the health of women and newborns. Whilst we cannot confirm that health seeking behaviour increased as a result of the intervention, FGD respondents almost unanimously agreed that ANC had increased, but were far less insistent about an increase in health facility deliveries. It would be strange for a social desirability bias to apply only to ANC and not health facility delivery. This raises questions on the accuracy of health facility records. When meeting with Kaduna SPHCDA to disseminate and discuss the data collected through the endline assessment, it was raised that data quality at health facilities may decrease as they become busier. This would suggest that the slight decline seen in the number of women attending ANC in Figure 2, may actually be a result of poorer record keeping as there were more women attending. This is speculation though and requires further interrogation.\u003c/p\u003e\n\u003cp\u003eSimilarly, whilst we cannot report reductions in maternal and perinatal deaths, the actions that the communities are implementing and the increased awareness of and agency to solve challenges that lead to deaths, will likely lead to significant reductions in maternal and perinatal mortality over time. In fact, health facility data suggests a decrease in the number stillbirths reported following the start of the project (Figure 5). Given the noted data quality issues, this requires further investigation, but could be a result of the reports from healthcare workers and community members that quality of care had improved, including timely referrals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study also found that social autopsies have been widely accepted by community members, many of whom noted the value of congregating, discussing issues, and creating solutions together. Our c-MPDSR model understood that socio-cultural and religious norms substantially influence agency and decision-making in Kaduna State, affecting health-seeking behaviour and practices that can result in negative outcomes for women and newborns. Because of this, we sought the support and participation of community leaders such as village heads, WDC members, and religious leaders in the model. Their involvement in the model\u0026rsquo;s activities was critical to the communities\u0026rsquo; buy-in and participation in social autopsies, helping to start shifting socio-cultural and religious norms and practices that can contribute to negative health outcomes for women and newborns. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn particular, it is possible the discussions have helped women to raise issues that they felt unable to voice individually at household level but felt comfortable to raise as part of a collective of women. We have since trained c-MDPSR committees in how to encourage design of gender transformative actions during the social autopsies to ensure the programme contributes more concretely towards gender equality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhilst social autopsies are valued by community members and effective in supporting communities to address causes of maternal and perinatal death at community level, they are resource intensive. C-MPDSR committee members require considerable training and supportive supervision before they are able to independently facilitate effective social autopsies. Kaduna SPHCDA was engaged from the outset and was committed to scaling up the model across the state. This commitment remains, however, limited domestic resources have so far prevented this. Instead, the state is working with other implementing partners to scale-up c-MPDSR through their existing programmes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite its cost, c-MPDSR offers a way for health systems to count maternal and perinatal deaths more accurately and provide tailored responses to help reduce such deaths. Not only this, but communities\u0026rsquo; benefit both from being involved in the process of c-MPDSR through increased awareness, agency, and collaboration to solve problems that lead to deaths as well as through the actions that they themselves design and implement to reduce deaths. Communities are often overlooked in health systems or seen simply as users; in Soba LGA we have shown that through c-MPDSR, communities can and should be active agents. Their participation will be key if Nigeria is to accelerate its reduction of maternal and perinatal mortality and have any hope of achieving its SDG goals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOur study had several limitations. Namely, our reliance on purposively sampled FGD participants, potential social desirability bias in their responses, and reported poor quality of health facility summary records. Whilst we took measures to reduce the impact of these limitations (for instance, well-trained enumerators and using health facility data to assess trends rather than absolute numbers), it is unclear if and to what extent they affected the results. Additionally, the short timeframe of the project\u0026rsquo;s implementation and long-term investment that behaviour change requires meant that it was unlikely clear increases in health facility attendance would be identified.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eANC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eAntenatal care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003ec-MPDSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003ecommunity-Maternal Perinatal Death Surveillance and Response\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eDHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eDemographic and Health Survey\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eFocus Group Discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eHCW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealthcare worker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eKII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eKey Informant Interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eLGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eLocal Government Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eMDG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eMillennium Development Goal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eMPDSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eMaternal Perinatal Death Surveillance and Response\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003ePHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003ePrimary Health Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003ePNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003ePost-natal care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003ePRHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003ePopulation and Reproductive Health Initiative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eSBA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eSkilled birth attendance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eSDG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eSustainable Development Goal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eSPHCDA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eState Primary Health Care Development Agency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eTBA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eTraditional birth attendant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eUNICEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eUnited Nations Children\u0026apos;s Fund\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eWDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eWard Development Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.245398773006134%\" valign=\"bottom\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.75460122699387%\" valign=\"bottom\"\u003e\n \u003cp\u003eWorld Health Organisation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e: All FGD and KII participants signed informed consent forms. The study received ethical approval from Kaduna State Ministry of Health, Health Research Ethical Committee and permission was sought from the Soba Local Government Health Authority Health Secretary and the community leaders of the two communities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e: Not Applicable (NA)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e: All transcripts are available? Data was collected under the proviso that it would remain confidential, as such is not shareable outside of the research team. Research tools and training materials can be accessed here: https://www.mamaye.org/index.php/gpg/community-mpdsr-c-mpdsr-tools\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e: No competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e:\u0026nbsp;This project was made possible with support from the Evidence for Action \u0026ndash; MamaYe programme, which is funded by the Bill \u0026amp; Melinda Gates Foundation and delivered by Options Consultancy Services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eAlice Tilton: designed and wrote the study protocols, research tools, analysed data, and wrote majority of the manuscript.\u003c/p\u003e\n\u003cp\u003eClara Ejembi: provided oversight for the project\u0026rsquo;s design, implementation. and data collection and contributed to writing and reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003eMoshood Salawu: managed implementation and quality assurance of the project and research study and inputted to the manuscript.\u003c/p\u003e\n\u003cp\u003eElkana Aliyu: managed implementation of the project and research study and inputted to the manuscript.\u003c/p\u003e\n\u003cp\u003eOladapo Shittu: provided oversight for the project\u0026rsquo;s design and implementation and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003ePunshak Wattle: supported implementation of the project and research study.\u003c/p\u003e\n\u003cp\u003eShade Olumeyin: supported implementation of the project and research study.\u003c/p\u003e\n\u003cp\u003eKhadijah Abdulkarim: supported implementation of the project and research study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePopulation and Reproductive Health Initiative (PRHI) who provided on-the-ground support to implement the project and research study. Kaduna State PHCDA, Soba LGA, the C-MPDSR committee members, and community members residing in Soba and Yakassai for their engagement, guidance, and time committed to the project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNasir N, Aderoba AK, Ariana P. Scoping review of maternal and newborn health interventions and programmes in Nigeria. BMJ Open. 2022;12(2):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet [Internet]. 2021;398(10302):772\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/S0140-6736(21)01112-0\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(21)01112-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Population Commission (NPC) [Nigeria], ICF. Nigeria Demographic Health Survey 2018 [Internet]. The DHS Program ICF Rockville, Maryland, USA. 2019. p.\u0026nbsp;748. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dhsprogram.com/publications/publication-fr359-dhs-final-reports.cfm\u003c/span\u003e\u003cspan address=\"https://dhsprogram.com/publications/publication-fr359-dhs-final-reports.cfm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO, UNFPA, WORLD BANK, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]. World Health Organisation. Geneva., Trends in maternal mortality 2000 to 2020: estimates by WHO, ; 2023. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/levels-and-trends-in-child-mortality-report-2021%0Ahttps://www.unicef.org/ghana/REALLY_SIMPLE_STATS_-_Issue_1(1).pdf\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/levels-and-trends-in-child-mortality-report-2021%0Ahttps://www.unicef.org/ghana/REALLY_SIMPLE_STATS_-_Issue_1(1).pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapira G, Ahmed T, Drouard SHP, Amor Fernandez P, Kandpal E, Nzelu C, et al. Disruptions in maternal and child health service utilization during COVID-19: Analysis from eight sub-Saharan African countries. Health Policy Plan. 2021;36(7):1140\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed T, Roberton T, Vergeer P, Hansen PM, Peters MA, Ofosu AA, et al. 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National Strategic Health Development Plan II: Ensuring healthy lives and promoting the wellbeing of Nigerian populace at all ages. 2018;1\u0026ndash;136.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Ministry of Health Nigeira. Investment Case for Reproductive, Maternal, Newborn, Child, and Adolescent Health 2017\u0026ndash;2030. 2016. p.\u0026nbsp;1\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcArthur JW, Rasmussen K, Yamey G. How many lives are at stake? Assessing 2030 sustainable development goal trajectories for maternal and child health. BMJ [Internet]. 2018;360(February):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/doi:10.1136/bmj.k373\u003c/span\u003e\u003cspan address=\"doi:10.1136/bmj.k373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdewuyi EO, Khanal V, Zhao Y, David L, Bamidele OD, Auta A. Home childbirth among young mothers aged 15\u0026ndash;24 years in Nigeria: A national population-based cross-sectional study. BMJ Open. 2019;9(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdewuyi EO, Zhao Y, Auta A, Lamichhane R. Prevalence and factors associated with non-utilization of healthcare facility for childbirth in rural and urban Nigeria: Analysis of a national population-based survey. Scand J Public Health. 2017;45(6):675\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFapohunda BM, Orobaton NG. When Women Deliver with No One Present in Nigeria: Who, What, Where and So What? PLoS ONE. 2013;8(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Maternal death surveillance and response: Technical information for action to prevent maternal deaths. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Ministry of Health. National Guidelines for Maternal Perinatal Death Surveillance and Response. 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas LM, D\u0026rsquo;Ambruoso L, Balabanova D. Verbal autopsy in health policy and systems: A literature review. Vol.\u0026nbsp;3, BMJ Global Health. 2018. p.\u0026nbsp;1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrata N, Gerdts C, Gessessew A. An innovative approach to measuring maternal mortality at the community leve in low-resource settings using mid-level providers. NIH Public. 2013;20(39):196\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBayley O, Chapota H, Kainja E, Phiri T, Gondwe C, King C, et al. Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: A pilot study in rural Malawi. BMJ Open. 2015;5(4):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahato PK, Waithaka E, van Teijlingen E, Pant PR, Biswas A. Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries. WHO South-East Asia J public Heal. 2018;7(1):24\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: A comprehensive literature review to examine the concept and the development of the method. Popul Health Metr. 2011;9:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoyer CA, Johnson C, Kaselitz E, Aborigo R. Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature. Glob Health Action [Internet]. 2017;10(1):1\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/16549716.2017.1413917\u003c/span\u003e\u003cspan address=\"10.1080/16549716.2017.1413917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank. A Better Future for All Nigerians: 2022 Poverty Assessment. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaduna State Government. Kaduna State Public Health Emergency Preparedness and Response Plan (draft). 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaduna State Government. Kaduna State Strategic Health Development Plan II. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaduna State Bureau of Statistics. Kaduna State General Household Survey Report. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetschonek S, Burlison J, Cross C, Martin K, Laver J, Landis RS, et al. Development of the just culture assessment tool: Measuring the perceptions of health-care professionals in hospitals. J Patient Saf. 2013;9(4):190\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGopichandran V, Chetlapalli SK. Dimensions and Determinants of Trust in Health Care in Resource Poor Settings - A Qualitative Exploration. PLoS ONE. 2013;8(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGale NK, Heath G, Cameron E, Sabina R, Redwood S. Using the Framework Method for the Analysis of Qualitative Dyadic Data in Health Research. BMC Med Res Methodol. 2013;31.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e In this study, poverty was measured using a consumption aggregate that was converted to per capita terms. The national poverty line was defined as 137,430 naira per person per year; this equates to roughly 1.93 USD 2011 PPP per person per day.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1: Example verbal autopsy reports conducted and compiled by the respective c-MPDSR committees.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVerbal autopsy report\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;for m\u003c/strong\u003e\u003cstrong\u003eaternal and perinatal death, Soba community\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e18/01/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of reporting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e20/01/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of Verbal Autopsy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e26/01/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of Social Autopsy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e07/02/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNarrative summary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003eA mother (30 years old) passed on after delivery of a stillbirth, her pregnancy was up to term. She had 8 pregnancies but only 2 children alive. Her first 5 deliveries were normal deliveries with no complication. During her 6th pregnancy, she developed some complication and had a caesarean section to deliver a stillbirth. The health worker informed her that her womb had been affected and advised her on birth spacing. Unfortunately, she got pregnant in less than 2\u0026nbsp;years,\u0026nbsp;and she had a normal delivery of a stillbirth. In less than 2 years, she got pregnant again and this pregnancy came with a lot of complications. She started attending ANC in a health clinic very close to her house at 8 weeks. She was ill throughout the pregnancy, suffering low strength, stomach pains, fever, headache amongst other symptoms. During her pregnancy, she did 10 scans.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbout two weeks before her demise, premature rupture of membranes meant she was losing liquid. One day before her demise, she felt very ill and returned to the health clinic where she receives ANC. The health worker assessed her and prescribed some drugs which she bought and drank, the health worker also referred her to a higher facility. That night, she passed two stools full of blood. The next morning, she proceeded to a private health clinic. The health worker examined her and told her the baby had passed on. He asked her to go elsewhere that he could not manage her case. She proceeded to another private health clinic. The health workers attempted to induce labour, when she discovered that the drip being passed was to induce her, she removed it and refused induction. Labour progressed and she delivered a stillbirth. This delivery was followed by excessive bleeding, she lost a lot of blood and required transfusion. Unfortunately, there was no blood nor available donor. While they were making arrangements for donor, she passed on. According to her mother she spent only about two hours in the last health facility before her demise. Her hospital cards were not made available during the verbal autopsy.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVerbal autopsy report for perinatal death, Yakassai community\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e14/03/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of reporting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e15/03/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of Verbal Autopsy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e18/04/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate of Social Autopsy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003e25/05/2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNarrative summary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"85.85690515806988%\" valign=\"top\"\u003e\n \u003cp\u003eA 28-year-old mother of 6 children with no evidence of antenatal care, lost her baby about an hour after she was born. Mother never attended antenatal and never took any form of medication or traditional medicine in the course of her pregnancy. She started labor at about 6am in the morning and delivered a female baby at about 2pm in the afternoon. The baby was born weak and didn\u0026apos;t cry. Mother and baby were not taken to the hospital. According to the mother, the baby was not given any medication neither traditional nor modern medicines. Soon after being born, the baby\u0026rsquo;s color changed, and she started to breathe very fast until she suddenly stopped breathing around 3pm.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Actions taken by community members between November 2021- July 2022, presented in line with the 3 Delays Model\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.84500745156483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.15499254843517%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.84500745156483%\" valign=\"top\"\u003e\n \u003cp\u003eDelay 1: Deciding to seek appropriate medical help for an obstetric emergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.15499254843517%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eHealthcare workers (in particular, Community Health Extension Workers and Junior Community Health Extension Workers), and religious, traditional and women leaders conducted awareness raising and sensitization of community members on the importance of health facility utilization, ANC attendance, health facility delivery, and dangers of patronizing untrained persons.\u003c/li\u003e\n \u003cli\u003eHusbands and grooms-to-be were instructed by the WDC and Village Head to give their standing consent for women to attend ANC and health facilities for delivery, even when they are not present. In Soba community, grooms-to-be must sign a form confirming this, which includes results of genotype testing to determine blood groups and potential for blood donorship if needed. This form must then be presented to religious leaders before marriage.\u003c/li\u003e\n \u003cli\u003eTBAs were ordered to stop transfusing blood and community members were encouraged to report such practices to the WDC. The WDC also held a meeting with all private practitioners and the LGA Reproductive Health coordinator and various community mobilization groups (c-MPDSR community informants, Voluntary Community Mobilizers, Community Oriented Resource Persons, Nigeria Urban Reproductive Health Initiative mobilizers). During the meeting, the WDC educated all participants on danger signs, emphasized the need for referrals, the importance of sensitization and mobilization of pregnant women for ANC. The private practitioners admitted that they engaged in many wrong practices and committed to stopping going forward. Since this meeting, no further cases have been reported.\u003c/li\u003e\n \u003cli\u003eWDC and health secretary raised awareness about the available health insurance schemes, most of which cover all maternity services, including scans and consumables. The Basic Contributory Healthcare Provision Fund was introduced to participants during a social autopsy, and they were encouraged to get their National Identity Management Commission cards as it is a condition for enrolment into the programme.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.84500745156483%\" valign=\"top\"\u003e\n \u003cp\u003eDelay 2: Reaching an appropriate obstetric facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.15499254843517%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNational Union of Road Traffic Workers (NURTW) agreed to transport pregnant women to health facilities for free at any time of day or night. The contact details of these drivers have been posted in the health facility, the Sarki\u0026rsquo;s palace, and distributed to c-MPDSR committee members, religious leaders, and village heads.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.84500745156483%\" valign=\"top\"\u003e\n \u003cp\u003eDelay 3: Receiving adequate care when a facility is reached\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.15499254843517%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMembers of a local Community Based Organisation found out their blood types and committed to donating blood regularly as well as being available in cases of emergency.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHealth facilities have adapted their rotas to ensure that there is always a female healthcare worker available, including on each night shift, and healthcare workers were reminded that they must attend their shifts.\u003c/li\u003e\n \u003cli\u003eHealthcare workers were reminded that no community member is to pay for services relating to ANC and delivery, pregnant women will only be required to provide consumables (e.g., syringe and needles, detergents) to be used directly for them when the health facility is out of supply.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maternal death, perinatal death, community health, health seeking behaviour, verbal autopsy, social autopsy, primary healthcare","lastPublishedDoi":"10.21203/rs.3.rs-3285937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3285937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch4\u003eBackground: There is low utilisation of antenatal care, health facility delivery, and post-natal care in Kaduna State, Nigeria, contributing to high maternal and perinatal mortality. Our research aimed to determine if community-Maternal and Perinatal Death Surveillance and Response, inclusive of verbal and social autopsies, increased antenatal care coverage (ANC), facility deliveries, and postnatal care coverage (PNC).\u003c/h4\u003e\n\u003ch4\u003eMethods: Mixed methods were used to monitor and evaluate the project. Data sources included health facility summary data from January 2021 to December 2022, Key Informant Interviews (KIIs), and Focus Group Discussions (FGDs) with health care workers from local facilities and men and women from the two communities. Indicators analysed included ANC coverage, skilled birth attendance rate, PNC coverage and qualitative indicators linked to trust of healthcare workers, blame for adverse events, and adoption of remedies to modifiable causes of maternal and or perinatal deaths. Quantitative and qualitative analyses were done on Microsoft Excel.\u003c/h4\u003e\n\u003ch4\u003eResults: Social autopsies were found to be acceptable and valued by community members. Actions developed may have had a lifesaving impact: maternity clinic run by an unskilled attendant was closed down, 24-hour free transportation for pregnant women provided by taxi drivers, and pre-emptive blood donations by community members to support emergency preparedness for childbirth. Qualitative data suggested that c-MPDSR led to increases in health facility attendance for antenatal care, improved quality of care, and increased trust between community members and health facility staff.\u003c/h4\u003e\n\u003ch4\u003eConclusions: c-MPDSR with verbal and social autopsies supports communities in Kaduna State to identify and discuss the causes of maternal and perinatal deaths and design actions that save lives and improve the health of women and newborns.\u003c/h4\u003e","manuscriptTitle":"Implementing Community-Maternal and Perinatal Death Surveillance and Response to identify and prevent maternal and perinatal mortality in Kaduna State, Nigeria: Results and lessons from a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-21 17:43:10","doi":"10.21203/rs.3.rs-3285937/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14f02bbe-12a3-43db-861a-e7d7bdb89b19","owner":[],"postedDate":"September 21st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-02T16:05:52+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-21 17:43:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3285937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3285937","identity":"rs-3285937","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}