Abstract: Using multi-level partnerships and mixed research methods to reduce maternal mortality

The following abstract was presented at the Implementation Science and Global Health satellite meeting on March 17, 2010 at Bethesda, Maryland.


Daniel Perlman, PhD
Research Medical Anthropologist
Co-Director, Bixby/FIC Population and Health Program, Nigeria
Bixby Center for Population, Health & Sustainability
University of California, Berkeley


  • Malcolm Potts, MB, BChir, PhD, FRCOG, Bixby Center for Population, Health & Sustainability, University of California, Berkeley

FIC Award


Conducting research and translating that research into policy can present daunting challenges in low-resource settings. With one of the lowest contraceptive prevalence rates, high poverty and female illiteracy rates, Northern Nigerian has one of the highest maternal mortality ratios and fastest rates of population growth in the world.

The Population and Reproductive Health Partnership (PRHP) is a 5-year collaboration between the University of California, Berkeley and Ahmadu Bello University in Northern Nigeria. The goal of this FIC funded collaboration is to enhance the capacity of Nigerian investigators to carry out community-based research leading to innovative approaches to the prevention of maternal mortality and morbidity.

The PRHP is meeting this goal through an alliance of interlinking partnerships and employs a creative mixture of research methods. The program is based at Ahmadu Bello University in Zaria, Nigeria. Its technical advisory group, which governs the partnership, is made up of prominent Nigerian researchers, medical practitioners, and leaders of non-governmental organizations. 

Each year, a cohort of 12 postdoctoral fellows is trained within the context of a research program based in five communities and health facilities in the Zaria area. Community members and health facility staff help identify key problems to be studied, assist with the formulation of research questions, and utilize research findings to improve maternal health and the quality of care provided in health facilities. The postdoctoral fellows receive intensive practice-based training in ethnographic methods.  Their ethnographic fieldwork has increased their understanding of the challenges that rural Nigerians face in accessing quality health care and has affected the way they see their own medical practice and plans for future research.  This foundation in ethnography and community-based participatory research is complemented and strengthened by quantitative research methods.

This mixed-method approach has drawn the training program in exciting new directions. After applying the three delays model to their qualitative data, one of the research groups found that of the three delays—the delay in deciding to seek care, the delay in reaching a health care facility, and the delay in receiving adequate care at the facility—the third delay appeared to be the most significant contributor to maternal mortality. 

At that point, the fellows and their mentors developed an innovative verbal autopsy format employing a series of open-ended interviews that provided an hour-by-hour account of the circumstances leading to each woman’s death.  They followed-up with a standard verbal autopsy questionnaire to determine the medical cause of death. The third delay was again found to be the most significant factor underlying the women’s deaths.

The next step was to investigate the problems at the facility level. Under the supervision of an experienced OB/GYN from UC Berkeley, the PRHP carried out an ethnographic assessment of emergency obstetric care in primary and secondary facilities serving the three collaborating communities. Understanding the ways in which inadequate hospital infrastructure (such as lack of electricity) impaired the delivery of obstetric care led to the development of solar energy systems that could light operating rooms, power blood bank refrigerators and ultrasound machines, and run communications equipment.  These innovations catalyzed the founding of a US based non-profit that is working to improve and disseminate these technologies in Nigeria and in other low-resource settings. 

The community-based research also led to an innovative partnership between the PRHP and village PTAs, schools, and religious associations to promote girls education and increase the age of marriage.  The present year’s cohort is about to begin a mixed method study that will build on the facility ethnographies.  The research—funded by the Population Council and the MacArthur Foundation—will engage facility staff in the assessment of obstetric practices and development of interventions to improve the quality of services.

The presentation will describe each of these collaborations and conclude with an analysis of the problems, difficulties and disappointments the PRHP encountered as it pursued these multilevel partnerships.

Updated April 2010