The COVID-19 Pandemic's Impact on Health Service Utilization Among Pregnant Women in Three Nigerian States: A Mixed Methods Study.

OBJECTIVE: COVID-19 disrupted health service delivery and weakened global and national health systems. The objective of this study was to describe the changes in health service utilization in three local government areas (LGAs) in Nigeria and examine factors involved. METHODS: A cross-sectional mixed-methods approach was used. A total of 315 pregnant women seen for antenatal care in 80 health facilities in three LGAs between October 1 and November 30, 2020, participated in exit interviews; 93 women participated in focus group discussions (FGDs). Descriptive analyses and a multivariable logistic analysis were conducted to examine associations between characteristics and decreased service utilization. Content analysis was used to identify the emerging themes related to health service utilization during the pandemic. RESULTS: One quarter of women reported that they reduced or ceased health service. The biggest reported changes were in immunization (47 to 30%, p < 0.001) and a small but statistically significant decline in antenatal care (98.7 to 93.8%, p < 0.001) was observed. Qualitative findings show that lockdowns, transportation issues, increased costs and fear of contracting COVID-19 or being labeled as COVID-positive were the most common reasons for not seeking care during this period of the pandemic. CONCLUSIONS: The pandemic negatively impacted health service utilization amongst pregnant women in Nigeria. A better understanding of differences in state response could help inform future actions. The findings highlight the need for health systems to consider how to facilitate service utilization during a pandemic, such as providing safe transport or increasing outreach, and to minimize stigma for those seeking care.

Retrospective evaluation of referral by community health workers on the uptake of intermittent preventive treatment of Malaria in pregnancy in Ohaukwu, Ebonyi State, Nigeria.

BACKGROUND: The World Health Organization recommends a minimum of three doses of quality-assured sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp), in moderate to high malaria transmission areas in sub-Saharan Africa. Currently, coverage of IPTp lags behind coverage of antenatal care (ANC) visits; in Nigeria, 57% of women attended four or more ANC visits, whereas only 17% received the recommended three or more doses of IPTp. The innovative program aimed to close this gap by providing counseling on the benefits of comprehensive ANC, referral to ANC and community distribution of IPTp (C-IPTp), complementing IPTp at ANC. The study aimed to examine whether CHW referral to ANC improved the likelihood of receiving three or more doses of IPTp. METHODS: The data for this study were extracted from the maternity record books of 1437 pregnant women seen at 25 public health facilities in Ebonyi State, Nigeria. The outcome of interest was defined as the receipt of three or more doses of IPTp (IPTp3) and the independent variable was referral to ANC by a community health worker for any visit. Descriptive statistics were reported and the results from the multi-level regressions are reported as adjusted odds and prevalence ratios with corresponding 95% confidence intervals. RESULTS: Of the 936 women included in the analysis, 24.47% received the recommended three or more IPTp doses and 61.32% were referred by a community health worker (CHW) for at least one ANC visit. There was no difference in the mean number of ANC visits between women who received C-IPTp and those who received IPTp exclusively at a facility (2.40 vs 2.52; p = 0.374). There were no maternal characteristics associated with CHW referral. Women who were referred by a CHW had 60% greater odds (95% CI, 1.08-2.38) of receiving IPTp3 than those who were never referred. CONCLUSION: The results indicate that CHW referrals conducted within a C-IPTp program are associated with higher IPTp uptake but not fewer ANC visits and that CHWs applied the referral process equally. This strengthens the evidence base for C-IPTp scale-up, which could have a large impact in sub-Saharan Africa in mitigating existing health systems issues.

Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based trainings among health workers on day of birth care in Nigeria; a cluster randomized controlled trial.

BACKGROUND: The aim of this study was to compare health workers knowledge and skills competencies between those trained using the onsite simulation-based, low-dose, high frequency training plus mobile mentoring (LDHF/m-mentoring) and the ones trained through traditional offsite, group-based training (TRAD) approach in Kogi and Ebonyi states, Nigeria, over a 12-month period. METHODS: A prospective cluster randomized controlled trial was conducted by enrolling 299 health workers who provided healthcare to mothers and their babies on the day of birth in 60 health facilities in Kogi and Ebonyi states. These were randomized to either LDHF/m-mentoring (intervention, n = 30 facilities) or traditional group-based training (control, n = 30 facilities) control arm. They received Basic Emergency Obstetrics and Newborn Care (BEmONC) training with simulated practice using anatomic models and role-plays. The control arm was trained offsite while the intervention arm was trained onsite where they worked. Mentorship was done through telephone calls and reminder text messages. The multiple choice questions (MCQs) and objective structured clinical examinations (OSCEs) mean scores were compared; p-value < 0.05 was considered statistically significant. Qualitative data were also collected and content analysis was conducted. RESULTS: The mean knowledge scores between the two arms at months 3 and 12 post-training were equally high; no statistically significant differences. Both arms showed improvements in composite scores for assessed BEmONC clinical skills from around 30% at baseline to 75% and above at end line (p < 0.05). Overall, the observed improvement and retention of skills was higher in intervention arm compared to the control arm at 12 months post-training, (p < 0.05). Some LDHF/m-mentoring approach trainees reported that mentors' support improved their acquisition and maintenance of knowledge and skills, which may have led to reductions in maternal and newborn deaths in their facilities. CONCLUSION: The LDHF/m-mentoring intervention is more effective than TRAD approach in improving health workers' skills acquisition and retention. Health care managers should have the option to select the LDHF/m-mentoring learning approach, depending on their country's priorities or context, as it ensures health workers remain in their place of work during training events thus less disruption to service delivery. TRIAL REGISTRATION: The trial was retrospectively registered on August 24, 2017 at ClinicalTrials.Gov: NCT03269240.

Quality of labour and uncomplicated delivery care: a formative assessment of selected health facilities in Ebonyi and Kogi States, Nigeria.

Maternal Child Survival Program (MCSP) worked in Ebonyi and Kogi States between 2014 to 2018 to improve quality of maternal, child and newborn health care. A formative assessment was conducted in selected health facilities to examine the quality of care received by mothers and their newborns at all stages of normal birth on the day of birth. Health providers attending deliveries at 13 facilities in the two states were observed by trained health professionals. Forty health facilities with a high volume of at least 50 Antenatal Care visits per month and deliveries were purposively selected from 120 quality improvement health facilities. Screening for danger signs at admission was conducted for only 10.5% cases in labor and providers adhered to most recommended infection prevention standards but only washed hands before birth in 19.5% of cases. Chlorhexidine gel was applied to the newborn's umbilical stump in only 2% cases while partograph was used in 32% of the cases. No newborns received the full package of essential care. Potentially harmful practices were observed especially holding newborn babies upside down in 32% cases. Improved provider training and mentoring in high-quality care on the day of birth and strengthened supportive supervision may help to reduce maternal and newborn morbidity and mortality.

Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based training approaches on day of birth care among maternal and newborn healthcare providers in Ebonyi and Kogi States, Nigeria; a randomized controlled trial.

BACKGROUND: There is limited information from low and middle-income countries on learning outcomes, provider satisfaction and cost-effectiveness on the day of birth care among maternal and newborn health workers trained using onsite simulation-based low-dose high frequency (LDHF) plus mentoring approach compared to the commonly employed offsite traditional group-based training (TRAD). The LDHF approach uses in-service learning updates to deliver information based on local needs during short, structured, onsite, interactive learning activities that involve the entire team and are spaced over time to optimize learning. The aim of this study will be to compare the effectiveness and cost of LDHF versus TRAD approaches in improving knowledge and skill in maternal and newborn care and to determine trainees' satisfaction with the approaches in Ebonyi and Kogi states, Nigeria. METHODS: This will be a prospective cluster randomized control trial. Sixty health facilities will be randomly assigned for day of birth care health providers training through either LDHF plus mobile mentoring (intervention arm) or TRAD (control arm). There will be 150 trainees in each arm. Multiple choices questionnaires (MCQs), objective structured clinical examinations (OSCEs), cost and satisfaction surveys will be administered before and after the trainings. Quantitative data collection will be done at months 0 (baseline), 3 and 12. Qualitative data will also be collected at 12-month from the LDHF arm only. Descriptive and inferential statistics will be used as appropriate. Composite scores will be computed for selected variables to determine areas where service providers have good skills as against areas where their skills are poor and to compare skills and knowledge outcomes between the two groups at 0.05 level of statistical significance. DISCUSSION: There is some evidence that LDHF, simulation and practice-based training approach plus mobile mentoring results in improved skills and health outcomes and is cost-effective. By comparing intervention and control arms the authors hope to replicate similar results, evaluate the approach in Nigeria and provide evidence to Ministry of Health on how and which training approach, frequency and setting will result in the greatest return on investment. TRIAL REGISTRATION: The trial was retrospectively registered on 24th August, 2017 at ClinicalTrials.Gov: NCT03269240 .

Acceptability of smart locker technology for dispensing chronic disease medication among patients and healthcare providers in Nigeria.

Smart lockers are automated delivery machines. They have been used in dispensing ARVs and Tuberculosis medication to chronically ill patients in South Africa, Kenya, and Eswatini. However, there is no evidence of smart lockers in dispensing chronic disease medication in Nigeria. This study aimed to assess the acceptability of smart lockers in dispensing chronic disease medication and to describe the barriers to accessing care among patients with chronic diseases medication in 5 states in Nigeria. We conducted a cross-sectional study among healthcare workers and patients living with chronic diseases in five Nigerian states of Adamawa, Akwa Ibom, Cross River, Benue, and Niger between November and December 2021. A total of 1,133 participants were recruited (728 patients and 405 healthcare workers). The results revealed that most patients and healthcare workers agreed that using smart lockers for drug dispensing will lead to reduced transportation costs, hospital waiting times, the workload of healthcare workers, and decongestion of health facilities. The majority of the patients living with chronic diseases (43%) and healthcare workers (51%) showed high acceptability for the use of smart lockers. The use of smart lockers in dispensing chronic disease medication in Nigeria is feasible, and patients and healthcare workers are willing to accept the smart lockers, provided that a patient-centred implementation strategy is developed.