Table 1.

Demand creation strategies implemented together with ETS

Strategy	Rationale
Safe space support groups for married adolescents Married women younger than 25 years meet weekly for 6 months in a setting where they are encouraged to freely share their views and perceptions of their health and that of their children. Meetings are facilitated by health care providers who use songs and drama to encourage utilization of maternal and child health services and the use of E TS during obstetric emergencies. Participants are mentored on a variety of issues, including: • Reproductive health and family planning • Danger signs in pregnancy, labor, delivery, and the immediate postpartum period • What to do when a child is sick • Immunization • Health-related decision making • Basic communication skills	Adolescent marriage remains a common practice in northern Nigeria.16 According to the 2013 Demographic and Health Survey, the median age at first marriage of women aged 25–49 years in Katsina state for example, was about 15 years.17 Married adolescents are especially vulnerable because they are often culturally and socially constrained in expressing their opinions and in making decisions concerning their health and that of their children.18–21
Support groups for married men Men who are married to young women meet several times to learn about issues related to the health of pregnant women and children. Local young married men are trained to serve as group mentors and to recruit men to the support groups. The curriculum is parallel to that of young women, but with an added emphasis on the importance of providing their wives with a standing approval to seek health care for themselves and their children when needed. Support group participants are told about the ETS and are encouraged to use them in emergencies.	Northern Nigeria society is patriarchal and this makes men the leaders and ultimate decision makers within the household and community. Women’s access to healthcare services for themselves and their children are often under the direct influence of their husbands.22,23 Men often do not educate themselves on maternal and child health issues, considering these to be women’s business.24
Sensitizing religious leaders Religious leaders are trained to better understand issues relating to maternal and child health and are tasked with promoting good health-seeking behaviors among their followership, with emphasis on men granting their wives standing approval to seek and utilize health care for themselves and their children, especially during emergencies, including using ETS. The trained religious leaders then engage with community members, mostly their male followers, in sermons during religious worship.	Islam is a complete way of life in northern Nigeria, governing every aspect of life and all community and household decisions. Religious leaders, therefore, are highly respected.25,26
Training TBAs to facilitate referrals TBAs have been operating in the project states for several years. With this intervention, they are trained specifically in demand creation and serve as linkages between health facilities, pregnant women, and the ETS program.	Many women in northern Nigeria prefer to deliver their babies at home, often completely alone. They do so because this is how it has always been done, and so as not to be considered cowards.27 TBAs bring health services to these women in their homes.

Abbreviations: ETS, emergency transport schemes; TBAs, traditional birth attendants.