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.

What is needed to improve quality of implant removal services in Nigeria? results of a landscape assessment.

Introduction: Stunning recent increases in subdermal contraceptive implant use, especially in sub-Saharan Africa, necessitate availability of quality implant removal services. In Nigeria, service delivery capacity and coverage for removal are lacking, despite strong government commitment and rapid uptake; there is a dearth of knowledge about barriers to quality implant removals in Nigeria. Methods: To determine access to and quality of contraceptive implant removal services, a landscape assessment was conducted in two states in Nigeria, focusing on four conditions for quality delineated in the Global Implant Removals Task Force framework. This mixed-methods approach integrated results from a desk review, a survey of health facilities and family planning managers, review of implant service statistics, and key informant interviews with providers and diverse stakeholders. Results: Seventy percent of providers (N = 21 of 30) had experienced problems performing implant removal, usually due to deeply inserted implants and equipment shortages. Providers had low confidence in performing removal and poor knowledge of implant removal steps. No facilities assessed had comprehensive equipment required for implant removal. Few facilities maintained systems or referral pathways to support difficult removals; difficult removals are absent from training manuals, and no formal trainings have been conducted. While most facilities collect data on removals, family planning dashboards do not capture it; few facilities use data for quality improvement. Conclusion: This study identified numerous challenges to quality implant removal, including poorly trained providers, inadequate supplies, underutilization of data on removals, and inability to manage difficult removals. As demand for implant removals skyrockets, providers need improved training in implant removal, appropriate job aids, supportive supervision, and effective procurement systems to ensure availability of supplies and equipment for removal. Tracking removals and reasons for removal in information systems and the Family Planning dashboard could sensitize providers to need for implant removals and improve data for decision-making in facilities and health systems.

Gender discrimination as a barrier to high-quality maternal and newborn health care in Nigeria: findings from a cross-sectional quality of care assessment.

BACKGROUND: Poor reproductive, maternal, newborn, child, and adolescent health outcomes in Nigeria can be attributed to several factors, not limited to low health service coverage, a lack of quality care, and gender inequity. Providers' gender-discriminatory attitudes, and men's limited positive involvement correlate with poor utilization and quality of services. We conducted a study at the beginning of a large family planning (FP) and maternal, newborn, child, and adolescent health program in Kogi and Ebonyi States of Nigeria to assess whether or not gender plays a role in access to, use of, and delivery of health services. METHODS: We conducted a cross-sectional, observational, baseline quality of care assessment from April-July 2016 to inform a maternal and newborn health project in health facilities in Ebonyi and Kogi States. We observed 435 antenatal care consultations and 47 births, and interviewed 138 providers about their knowledge, training, experiences, working conditions, gender-sensitive and respectful care, and workplace gender dynamics. The United States Agency for International Development's Gender Analysis Framework was used to analyze findings. RESULTS: Sixty percent of providers disagreed that a woman could choose a family planning method without a male partner's involvement, and 23.2% of providers disagreed that unmarried clients should use family planning. Ninety-eight percent believed men should participate in health services, yet only 10% encouraged women to bring their partners. Harmful practices were observed in 59.6% of deliveries and disrespectful or abusive practices were observed in 34.0%. No providers offered clients information, services, or referrals for gender-based violence. Sixty-seven percent reported observing or hearing of an incident of violence against clients, and 7.9% of providers experienced violence in the workplace themselves. Over 78% of providers received no training on gender, gender-based violence, or human rights in the past 3 years. CONCLUSION: Addressing gender inequalities that limit women's access, choice, agency, and autonomy in health services as a quality of care issue is critical to reducing poor health outcomes in Nigeria. Inherent gender discrimination in health service delivery reinforces the critical need for gender analysis, gender responsive approaches, values clarification, and capacity building for service providers.

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 .

Post-Ebola situational assessment of opportunities for capacity building at the national obstetrics and gynecology referral hospital in Sierra Leone.

OBJECTIVE: To describe a site assessment of the Princess Christian Maternity Hospital (PCMH; Freetown, Sierra Leone), the national referral center for reproductive, maternal, newborn, child and adolescent health (RMNCAH) services and logical site for focused efforts to train and expand the RMNCAH workforce in Sierra Leone. METHODS: In April 2016, a mixed-methods assessment approach was used involving facility observation and staff interviews using the WHO's Service Availability and Readiness Assessment (SARA) tool. Quantitative and qualitative data were obtained. RESULTS: PCMH had 150 inpatient beds and provided care for more than 4600 deliveries in 2015. The number of maternal deaths increased at a rate of approximately 40% per month from January 2015 to June 2016 (P=0.005). Key factors requiring attention were identified in the categories of infrastructure and supplies, RMNCAH services, and human resources. CONCLUSION: SARA provided a framework for identifying strengths and weaknesses in infrastructure and supplies, RMNCAH services, and human resources. The process described might serve as a model for evaluating obstetrics and gynecology training facilities in low- and middle-income countries. Human resources are currently insufficient for the volume and complexity of patients at PCMH. Numerous opportunities exist for strengthening healthcare services and capacity building in Sierra Leone.

An assessment of serum prolactin levels among infertile women with galactorrhea attending a gynecological clinic North-West Nigeria.

BACKGROUND: Galactorrhea is a common manifestation of hyperprolactinemia but may not always be present in women with hyperprolactinemia. This study was, therefore, undertaken to assess the serum prolactin levels of infertile women presenting with galactorrhea and to determine the prevalence of hyperprolactinemia among them. MATERIALS AND METHODS: This was a retrospective study of serum prolactin levels of 63 female partners of infertile couples attending the gynecological clinic of Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria, who were found to have galactorrhea from January 1, 2012, to December 31, 2013. Ethical clearance was obtained. Solid phase enzyme-linked immunosorbent assay was used to measure serum prolactin. Sociodemographic characteristics were determined. The data obtained were analyzed using SPSS version 17.0 statistical software. Absolute numbers and simple percentages were used to describe categorical variables. Similarly, quantitative variables were described using measures of central tendency (mean, median) and measures of dispersion (range, standard deviation) as appropriate. RESULTS: The average age of the women was 27.9 ± 5.6 years. In half of the cases (50%), galactorrhea was associated with menstrual disturbances, mainly amenorrhea (23.3%). Although most (63.3%) of the clients had normal serum prolactin level despite being galactorrheic, averagely there was a marked elevation in serum prolactin of as high as 40.3 ± 52.3 ng/mL. CONCLUSION: We conclude, therefore, that the prevalence of hyperprolactinemia in this study was low when compared with other studies and that galactorrhea does not always indicate raised serum prolactin levels.

An assessment of stillbirths in a tertiary hospital in northern Nigeria.

OBJECTIVE: This study was undertaken to determine the stillbirth rate and causes in Birnin Kudu, North-west, Nigeria. METHOD: This was a retrospective study. It involved 705 women who presented for delivery in Federal Medical Centre, Birnin Kudu and had stillbirths. The hospital maternity and theatre registers were used to identify the women who had stillbirth during the study period from 1 January 2008 to 31 December 2012. The data obtained were analyzed using SPSS version 16.0 statistical software. Significant association between socio-demographic/obstetrics factors and stillbirth were tested using the chi-square test and p < 0.05 was considered significant. RESULT: The stillbirth rate was 170 per 1000 births. Most of the women who had stillbirths (29.1%) were aged 20-24 years, followed by those aged ≥35 years (27.1%). The uneducated women were more than those who had only primary education and this was statistically significant (p = 0.001). The mean parity of the women was 5 ± 3. Obstructed labour was the common cause of stillbirth followed by placental abruption (17.73%) and pre-eclampsia/eclampsia (13.33%). CONCLUSION: The stillbirth rate reported in this study was higher than those reported from other regions of Nigeria and obstructed labour was the common cause.