Community Health Extension Workers: Increasing Access to Contraceptive Implants in Nigeria
We know that a key piece of solving the contraceptive non-use puzzle is increasing access to a variety of methods. But for women in rural areas, options are limited. In Nigeria, only 10% of married women 15-49 years old use modern contraception—compared to 26% across sub-Saharan Africa. Nigeria, like many of its neighbors, suffers from a shortage of health workers trained to provide modern contraception. This is particularly true of long-acting reversible contraceptive methods (LARCs), like implants and IUDs. Long-acting methods help women prevent pregnancies for up to five years at a time and are therefore proven to be the some of the most effective in preventing unintended pregnancies. They are often the best solution for a rural woman who does not have ready access to a health center where she can refill her pills or supply of condoms on a regular basis.
The Nigerian government recognized that the lack of trained providers was hindering progress on contraceptive uptake. In 2014, it passed a policy to expand the family planning services provided by Community Health Extension Workers (CHEWs). For the first time, CHEWs could provide injectables and long-acting reversible contraceptive implants at primary health facilities.
Despite this step forward, a year later CHEWs in many states had not received adequate training and resources and they were still not offering implants. Policymakers at the state level needed a more practical understanding of what the policy meant for both feasibility and safety. In particular, they needed local evidence that CHEWs could safely and effectively administer implants. To address this issue and to encourage implementation of the law, Pathfinder, through our Evidence to Action Project (E2A), conducted a study from April 2015 to June 2016 in Cross River and Kaduna states to determine if CHEWs could safely provide implants.
The study employed a competency-based training approach, then assessed the effects of CHEWs providing implants on contraceptive uptake at health facilities in select Local Government Areas. In addition to competency-based training, the CHEWs also conducted voluntary “demand generation” outreach activities to increase community members’ awareness, knowledge, and acceptance of the LARC services they provide, including implants.
The results were clear. The study showed that CHEWs are capable of providing quality implant services to their clients. We learned that clients were equally satisfied with provision of implants from CHEWs (intervention sites) and nurses (comparison sites). However, the study also shows that neither policy change nor provider training alone is sufficient to increase women’s access to contraception.
Just like the policymakers who needed more evidence, communities need more information about reproductive health and the services available to them. Social norms that discourage use of contraception must also be addressed. Training CHEWs is not enough if no one is coming through the door to ask for information and services: There still needs to be adequate investment in community-based information sharing and demand generation.
At the end of the study, CHEWs reported that they felt confident providing services—most reported that their skills were “good” or “very good” and they required “none” or “little” supervision to offer the service. However, since competencies in implant services tended to decline over time during the study, there may be a need for additional supportive supervision and mentoring to maintain high-quality service provision. Taking these lessons to heart, Pathfinder, with support from USAID through E2A’s involvement in the Saving Mothers, Giving Life initiative in Cross River State, has started to scale up the implant services training for CHEWs to all primary health care facilities in the state.
Because of their links to the communities they serve, CHEWs are an effective way of connecting communities to sexual and reproductive services. As this study shows, with proper training and supervision, CHEWs can deliver quality services—something that is too often lacking in rural settings.