Strengthening approaches to reproductive and maternal health

Community health workers (CHWs) in Indonesia, often receive irregular training without regular mentoring (Widiasih et al., 2025), despite expanding responsibilities, from promoting posyandu (integrated health service post) visits, early detection, counseling, to outreach for service access targeting all life cycles. CHWs are encouraged to master 25 basic CHWs skills set by the Indonesian Ministry of Health, covering posyandu management, infant/toddlers services, maternal/postpartum care, adolescent services, and adult/elderly services. Limited support and diverse educational backgrounds can hinder consistent service skills. To address this, the Center for Indonesia's Strategic Development Initiative (CISDI) empowered CHWs for one one-year (July 2024–July 2025) and implemented supportive supervision (SS). The program provided training and mentorship via initial and refresher training, monthly posyandu meetings, and small-group coaching. It emphasized dialogue, reflection, and direct feedback from observations during posyandu and home visits.
Study assessed changes in CHWs' service skills after one year of SS. Using a pre–post self-assessment design (June 2024 and August 2025), 340 CHWs in 38 posyandu areas in Depok City and Bekasi District rated six skill domains on a four-point Likert scale (never–always). Paired t-tests examined baseline and endline, with Cohen's d for effect size.
Results showed significant improvement (p < 0.001) in most domains except anthropometry, which declined. This reflected CHW heightened self-awareness in anthropometry (conscious incompetence, Burch 1970). SS significantly enhanced CHWs' self-assessed skills. SS strengthened CHW performance and cultivated reflection and accountability. Targeted tools and training, grounded in social learning theory, are essential to education and communication.

To address the gap in ANC service access by pregnant adolescents in northern Nigeria, we sought to identify barriers that prevent them from attending ANC and develop an approach to improve attendance and support healthy pregnancies. Guided by the socio-ecological model, we examined barriers at multiple levels and developed an intervention to encourage positive care-seeking behaviors. We used a human-centered design process to identify barriers and design an intervention, which we evaluated through a quasi-experimental cohort study measuring ANC uptake, facility delivery, and postpartum family planning. Insights revealed limited planning among couples before pregnancy, restrictive norms around early ANC, girls' limited agency to seek appropriate care, cost concerns, and poor-quality or absent PPFP discussions. The intervention addressed these barriers through community-based pre-ANC classes offering referrals to government ANC services and outreach to husbands. Relative to the comparison group, intervention participants were more likely to attend ANC, deliver in a facility, and use family planning postpartum. Our work offers a model for an effective process for translating insights into program design as well as concrete approaches to advance maternal health care seeking among vulnerable populations.  

Background: Empathy-Based Counselling (EBC) is a transformative social and behavior change communication (SBCC) strategy that strengthens provider-client communication by fostering empathy, trust, and active listening to support informed family planning (FP) choices
Justification: Despite awareness of self-injection, fear, misinformation, and low self-efficacy continued to hinder women, necessitating an intervention that reframed provider client interaction as a communication driven behavior change process.
Objective: To document the contribution of empathy-centered SBCC approaches through EBC on DMPA-SC self-injection uptake and FP choices among women in Kwara State.
Methods: Routine family planning data were extracted from the DHIS2 platform across 160 health facilities in 16 LGAs, comparing DMPA-SC self-injection uptake before and after EBC training conducted in October 2024; data covered June-December 2024 (June-September as pre period and October-December as post period), and trends in the monthly proportion of DMPA-SC visits that were self-injected were analyzed
Findings: The proportion of self-injection declined to 42% during the training month but increased to 58% in November and 64% in December, reflecting a delayed but significant impact of the intervention; overall SI uptake rose from 48% in July to 64% in December, indicating a 16% increase and demonstrating improved confidence, reduced fear, and enhancing transitioning to self-injection.
Conclusion: EBC effectively addressed behavioral and psychological barriers, strengthened autonomy, improved method choice, and significantly increased DMPA-SC self-injection uptake, highlighting its value for FP programs and its potential for broader application in similar settings.

DMPA-SC self-injection (SI) is a proven high-impact practice that expands contraceptive access and strengthens women's autonomy, particularly in underserved communities. However, in Nigeria, restrictive national guidelines and systemic barriers limited its full potential. Previous policies prohibited first-time users from taking home doses and allowed returning users only two units, contributing to poor continuation, inconsistent community access, and reliance on facility-based services. Recognizing these challenges, The FMoH&SW in collaboration with reproductive health stakeholders, initiated a structured policy review aimed at improving continuity of care. The policy reform process used an evidence-driven, multi-stakeholder approach, combining barrier documentation, implementation learnings, global best practices, and ExpandNet scalability tools. Stakeholder mapping helped build consensus, while a national implementation roadmap clarified government commitments.
The revised national guideline now allows competent first-time users to receive three take-home doses, significantly reducing resupply challenges and supporting sustained contraceptive use. National data from SFH-led interventions sites (DISC, A360, and IntegratE) demonstrated measurable improvements in access and system efficiency, with a 35% increase in average monthly consumption, a 73% increase in stock received, and a 17% reduction in stock-on-hand at intervention sites.
The policy shift has major implications for SBCC practice. It requires strengthened provider empathy-based counselling, improved user-facing communication to support safe self-injection, and broader community norm-shifting strategies that normalize SI as a self-care method. Together, these efforts ensure continuity, autonomy, and long-term sustainability of community-based SI services in Nigeria.