Barriers to health in women of reproductive age living with or at risk of non-communicable diseases in Nigeria: a Photovoice study.

BACKGROUND: Nigeria has one of the highest maternal mortality ratios (MMR) globally with an MMR of 512 (per 100,000 live births) and the proportion of maternal deaths due to non-communicable diseases (NCDs) is increasing. While evidence shows that many of these deaths are preventable, limited attention is being paid to the unique vulnerabilities and experiences of women of reproductive age (WRA) with NCDs and their risk factors, as well as the barriers to the screening, diagnosis, and management of these diseases in Nigeria. METHODS: This study explored the lives of WRA in Lagos and Federal Capital Territory in Nigeria from May to June 2019 using a community-based participatory research (CBPR) methodology called Photovoice which is aligned with CBPR as it includes procedures such as the identification of important community issues, discussion of photo assignments and data analysis. Twenty-four women of reproductive age were provided with digital cameras and trained on how to capture photos that conveyed their current health, healthcare utilization and engagement, and experience journeys. Individual interviews with the women were held for an in-depth exploration of the photographs. The data was then analysed thematically. RESULTS: Six distinct themes were identified across the barriers highlighted by the women: food and nutrition, home and family, neighborhood-built environment, economic instability, religion and spirituality and low prioritization of self-care. These themes captured the challenge of reduced agency, limited contribution and participation, and a complex relationship between visible and invisible illness. CONCLUSION: The perspectives of WRA in Nigeria obtained through this qualitative research provided a strong substratum for understanding the environmental barriers that predispose WRA to NCDs in Nigeria. The results of the study are useful for the improvement of woman-centred services of prevention, diagnosis, and management of NCD risk factors across the maternal and reproductive health care continuum in Nigeria.

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.

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.

Assessing the operational effectiveness of a maternal and child health (MCH) conditional cash transfer pilot programme in Nigeria.

BACKGROUND: This paper provides insights into design and implementation of a Conditional Cash Transfer (CCT) pilot programme under the Subsidy Reinvestment and Empowerment Programme on Maternal and Child Health (SURE-P MCH) in Nigeria. The CCT day to day operations were independently assessed, from design to enrollment and pay out, in order to inform future CCT designs and implementation. METHODS: This study combined a desk review of SURE-P MCH CCT operational documents and retrospective, descriptive cross-sectional survey of 314 primary beneficiaries of the CCT scheme from 29 SURE-P MCH CCT designated health facilities between June - July 2015. The programme implementation manual (PIM) and several CCT monthly reports and articles obtained from the project implementation unit (PIU) were reviewed while structured questionnaire of (16) questions was used for face-to-face interviews with (30-33) CCT beneficiaries drawn from each of eight (8) participating states of Anambra, Bauchi, Bayelsa, Ebonyi, Kaduna, Niger, Ogun, and Zamfara and the Federal Capital Territory (FCT)-Abuja. Findings were analyzed and reported using R* statistical package (version 3.1.2). Subsequently a strengths, weaknesses, opportunities and threats (SWOT) analysis was conducted to identify key challenges and possible recommendations. RESULTS: The SWOT analysis indicated a robust design for the CCT programme, which would have enhanced operational effectiveness if implemented as designed. However, the programme faced several implementation challenges. For instance, though 65% of beneficiaries perceived CCT pay-out events to be orderly and well-organized, in some of the pilot states the events were marred with inconsistencies resulting in large crowds and increased waiting time for some beneficiaries. Similarly, only 40% of beneficiaries received the complete N5,000 (USD30) cash incentive, 28% received N1,000 (USD6) while others received either N2000 (USD12), N3000 (USD18) or N4000 (USD24). CONCLUSION: The CCT pilot had a robust design as a result of a successful proof of concept which preceded the pilot roll-out. However, its implementation was marred with several challenges ranging from untimely release of funds, limited monitoring and evaluation and other operational challenges. Future CCT programmes should understudy the SWOT analysis presented in this paper to improve the design and implementation of CCT programmes in Nigeria and other settings.

Perspectives of beneficiaries, health service providers, and community members on a maternal and child health conditional cash transfer pilot programme in Nigeria.

BACKGROUND: Our paper presents experiences and perceptions of beneficiaries, health service providers, and community members about a conditional cash transfer (CCT) programme piloted in Nigeria from April 2013 to May 2015 to boost demand for maternal, newborn, and child health services. METHODS: We conducted a descriptive cross-sectional retrospective study using both qualitative and quantitative methods. Personal interviews and focus group discussions (FGDs) were conducted between June and July 2015 for 314 CCT beneficiaries, 72 ward development committee (WDC) members, and 60 service providers (midwives, community health extension workers [CHEWs], and village health workers [VHWs]) including 29 officers-in-charge as key informants. Content analysis was applied to qualitative findings and grouped into themes of attitude, practices, CCT operations, payout, and perceived impact. RESULTS: Over 97% of beneficiaries affirmed that the cash incentive was very helpful and almost 70% opined that the free supply-side services were the real benefit. Majority of service providers applauded the programme though, with complaints about the increased workload. Community members applauded the scheme, with mixed feelings over some operational processes. CONCLUSION: Beneficiaries, service providers, and community members expressed deep satisfaction with the CCT programme and opined that antenatal care (ANC) and skilled birth delivery service utilization increased. Insights into some programmatic challenges are provided to enrich future CCT design and implementation.

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 .

Conditional cash transfer schemes in Nigeria: potential gains for maternal and child health service uptake in a national pilot programme.

BACKGROUND: This paper describes use of a Conditional Cash Transfer (CCT) programme to encourage use of critical MNCH services among rural women in Nigeria. METHODS: The CCT programme was first implemented as a pilot in 37 primary health care facilities (PHCs), in nine Nigerian states. The programme entitles women using these facilities up to N5,000 (approximately US$30) if they attend antenatal care (ANC), skilled delivery, and postnatal care. There are 88 other PHCs from these nine states included in this study, which implemented a standard package of supply upgrades without the CCT. Data on monthly service uptake throughout the continuum of care was collected at 124 facilities during quarterly monitoring visits. An interrupted time series using segmented linear regression was applied to estimate separately the effects of the CCT programme and supply package on service uptake. RESULTS: From April 2013-March 2014, 20,133 women enrolled in the CCT. Sixty-four percent of beneficiaries returned at least once after registration, and 80% of women delivering with skilled attendance returned after delivery. The CCT intervention is associated with a statistically significant increase in the monthly number of women attending four or more ANC visits (increase of 15.12 visits per 100,000 catchment population, p < 0.01; 95% confidence interval 7.38 to 22.85), despite a negative level effect immediately after the intervention began (-45.53/100,000 catchment population; p < 0.05; 95% CI -82.71 to -8.36). A statistically significant increase was also observed in the monthly number of women receiving two or more Tetanus toxoid doses during pregnancy (21.65/100,000 catchment population; p < 0.01; 95% CI 9.23 to 34.08). Changes for other outcomes with the CCT intervention (number of women attending first ANC visit; number of deliveries with skilled attendance; number of neonates receiving OPV at birth) were not found to be statistically significant. CONCLUSIONS: The results show that the CCT intervention is capable of significant effects on service uptake, although results for several outcomes of interest were inconclusive. Key lessons learnt from the pilot phase of implementation include a need to track beneficiary retention throughout the continuum of care as closely as possible, and avert loss to follow-up.

Prevalence of non-communicable diseases and risk factors of pre-eclampsia/eclampsia in four local government areas in Nigeria: a cross-sectional study.

OBJECTIVES: To assess the prevalence of non-communicable diseases (NCDs) and risk factors associated with pre-eclampsia and eclampsia (PE/E) in women of reproductive age (WRA) in Nigeria. DESIGN: A cross-sectional survey was administered to the entire study population. In the point-of-care testing, physical and biochemical measurements were taken in a subset of the participants. SETTING: The study was conducted in the Ikorodu and Alimosho local government areas (LGAs) in Lagos and the Abuja Municipal Area Council and Bwari LGAs in the Federal Capital Territory. PARTICIPANTS: Systematic random sampling was used to randomly select and recruit 639 WRA (aged 18-49 years) between May 2019 and June 2019. OUTCOME MEASURES: Prevalence of select NCDs (hypertension or raised blood pressure, diabetes or raised blood sugar levels, anaemia, truncal obesity and overweight/obesity) and risk factors associated with PE/E (physical activity, fruit and vegetable consumption, alcohol consumption and smoking). RESULTS: The prevalence of raised blood pressure measured among the WRA was 36.0% (95% CI 31.3% to 40.9%). Approximately 10% (95% CI 7.2% to 13.4%) of participants had raised blood sugar levels. About 19.0% (95% CI 15.3% to 23.2%) of the women had moderate or severe anaemia. Excluding WRA who were pregnant, 51.9% (95% CI 45.7% to 58.0%) of the women were either overweight or obese based on their body mass index. Approximately 58.8% (95% CI 53.8% to 63.6%) of WRA surveyed reported three to five risk factors for developing NCDs and PE/E in future pregnancies. CONCLUSIONS: The study identified a high prevalence of NCDs and associated PE/E risk factors in surveyed women, signifying the importance of early detection and intervention for modifiable NCD and associated PE/E risk factors in WRA. Further research is necessary to assess the national prevalence of NCDs.

The midwives service scheme in Nigeria.

Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth. To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas. The midwives are posted for 1 year to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care. The outcome of the MSS 1 year on has been an uneven improvement in maternal, newborn, and child health indices in the six geopolitical zones of Nigeria. Major challenges include retention, availability and training of midwives, and varying levels of commitment from state and local governments across the country, and despite the availability of skilled birth attendants at MSS facilities, women still deliver at home in some parts of the country.

Engaging Communities in Commodity Stock Monitoring Using Telecommunication Technology in Primary Health Care Facilities in Rural Nigeria.

BACKGROUND: With several efforts being made by key stakeholders to bridge the gap between beneficiaries and their having full access to free supplies, frequent stock-out, pilfering, collection of user fees for health commodities, and poor community engagement continue to plague the delivery of health services at the primary health care (PHC) level in rural Nigeria. OBJECTIVE: To assess the potential in the use of telecommunication technology as an effective way to engage members of the community in commodity stock monitoring, increase utilization of services, as well as promote accountability and community ownership. METHODS: The pilot done in 8 PHCs from 4 locations within Nigeria utilized telecommunication technologies to exchange information on stock monitoring. A triangulated technique of data validation through cross verification from 3 subsets of respondents was used: 160 ward development committee (WDC) members, 8 officers-in-charge (OICs) of PHCs, and 383 beneficiaries (health facility users) participated. Data collection made through a call center over a period of 3 months from July to September 2014 focused on WDC participation in inventory of commodities and type and cost of maternal, neonatal, and child health services accessed by each beneficiary. RESULTS: Results showed that all WDCs involved in the pilot study became very active, and there was a strong cooperation between the OICs and the WDCs in monitoring commodity stock levels as the OICs participated in the monthly WDC meetings 96% of the time. A sharp decline in the collection of user fees was observed, and there was a 10% rise in overall access to free health care services by beneficiaries. CONCLUSION: This study reveals the effectiveness of mobile phones and indicates that telecommunication technologies can play an important role in engaging communities to monitor PHC stock levels as well as reduce the incidence of user fees collection and pilfering of commodities (PHC) level in rural communities.

Prenatal care and basic emergency obstetric care services provided at primary healthcare facilities in rural Nigeria.

OBJECTIVE: To assess the availability of prenatal care and basic emergency obstetric care services at primary healthcare (PHC) facilities in rural Nigeria. METHODS: In total, 652 PHC facilities enrolled in the Midwives Service Scheme, a government-funded program designed to reduce the national shortage of skilled birth attendants, were surveyed. RESULTS: In all, 44.0% of the PHC facilities evaluated did not provide all components of prenatal care, and only 39.0% of all pregnant women nationwide attended prenatal care clinics 4 or more times. In addition, 52.2% of the facilities were not distributing insecticide-treated nets to pregnant women, while only 36.8% of the PHC facilities provided services to prevent mother-to-child transmission of HIV. By contrast, 70.0% of the PHC facilities had access to antibiotics for the treatment of uncomplicated sepsis. Only 11.0% of clinics reported the use of vacuum extraction during labor and 36.8% provided post-abortion care services. Treatment for pre-eclampsia and eclampsia was initiated at 40.0% and 28.0% of PHC facilities, respectively, prior to referral. CONCLUSION: The present study provides useful information on the state of prenatal and basic emergency obstetric care in rural Nigeria. The data obtained indicate that changes are needed to achieve related Millennium Development Goals.

An evaluation of diabetic retinopathy screening models.

BACKGROUND: The aim of the study was to evaluate three models of diabetic retinopathy screening in a North London Health Authority so as to advise on setting up a comprehensive screening programme. The study evaluated the models against their own objectives and standards published by the British Diabetic Association (BDA) and the Royal Colleges for diabetic retinopathy screening, and assessed service user and provider satisfaction. METHODS: Methods used were: analysis of the patient database and a case note review on uptake and coverage; follow-up for abnormal findings; comparisons of positive predictive values; postal questionnaire survey of service user satisfaction; semi-structured interviews of service providers. RESULTS: A total of 2230 people with diabetes were screened between March 1998 and August 2000. The general practitioner (GP) led model achieved 63 per cent coverage and the two optometrist models 24 per cent. The detection rate for sight-threatening diabetic retinopathy was 6 per cent and 2.5 per cent for the optometrists and GP models, respectively. Positive predictive values of 94 per cent, 90 per cent and 60 per cent, respectively, were established for the GP-led model, the optometrists using the retinal camera and the optometrists using indirect ophthalmoscopy only. Twenty-eight (45 per cent) of the 62 people with sight-threatening diabetic retinopathy failed to attend for further investigation. Service user and service provider satisfaction were high for all three models. CONCLUSION: The evaluation confirmed that all three methods of screening provided an effective service. The implementation of a district-wide diabetic retinopathy screening programme requires the establishment of a systematic call and recall system to achieve attendance for screening. A formal follow-up of people referred for specialist assessment and treatment should be part of the service.