Clients' perspectives on the utilization of reproductive, maternal, neonatal, and child health services in primary health centers during COVID-19 pandemic in 10 States of Nigeria: A cross-sectional study.

BACKGROUND: Reports from various parts of the world suggest that the COVID-19 pandemic may have severe adverse effects on the delivery and uptake of reproductive health, maternal, neonatal, and child health (RMNCH) services. The objective of the study was to explore women's experiences with utilization of RMNCH services during the COVID-19 pandemic in Nigeria, and to elicit their perceptions on ways to sustain effective service delivery during the pandemic. METHODS: A cross-sectional survey of 2930 women using primary health care facilities for antenatal, delivery, postnatal, and child care services before and after the onset of the pandemic in 10 States of Nigeria were interviewed with a semi-structured questionnaire. Data were collected on women's socio-demographic characteristics and pregnancy histories, the services they sought before and after the pandemic, the challenges they faced in accessing the services, their use of alternative sources of health care, and their recommendations on ways to sustain RMNCH service delivery during the pandemic. The data were analyzed with descriptive statistics, and multivariable logistic regression using SPSS 20.0. All the statistical analyses were two-tailed with a 95% confidence interval, and the p-value was set at 0.05. RESULTS: The logistic regression results showed that women were at least 56% more likely to report that they used family planning, antenatal, and delivery services before the pandemic than after the pandemic started, but 38% less likely to report use of postnatal services. The experience of difficulty accessing RMNCH services was 23% more likely after the pandemic started than before the pandemic. Three categories of recommendations made by the respondents on measures to sustain RMNCH delivery during the pandemic included 1) facility improvement, and staff recruitment and re-training; 2) free and readily accessible PHC services, and 3) the provision of social safety nets including transportation and palliatives. CONCLUSION: We conclude that the COVID-19 pandemic limited women's access to antenatal, delivery, and childcare services offered in PHCs in Nigeria. Addressing the recommendations and the concerns raised by women will help to sustain the delivery of RMNCH services during the COVID-19 pandemic and future epidemics or health emergencies in Nigeria.

Texting for life: a mobile phone application to connect pregnant women with emergency transport and obstetric care in rural Nigeria.

BACKGROUND: Difficulty in transportation to access skilled providers has been cited repeatedly as a major barrier to utilization of emergency obstetric care in Nigeria. OBJECTIVE: The objective of this paper is to describe the design, implementation, and outcomes of a mobile phone technology aimed at rapidly reaching rural Nigerian women who experience pregnancy complications with emergency transportation and access to providers. METHOD: The project was implemented in 20 communities in two predominantly rural Local Government Areas (LGAs) of Edo State, in southern Nigeria, as part of a larger implementation project aimed at improving the access of rural women to skilled pregnancy care. The digital health innovation named Text4Life, allowed women to send a brief message from their mobile phone to a server linked to Primary Health Care (PHC) facilities and to access pre-registered transport owners. Pregnant women were registered and taught to text short messages to a server from their mobile phones or those of a friend or relative when they experience complications. RESULTS: Over 18 months, 56 women out of 1620 registered women (3.5%) texted the server requesting emergency transportation. Of this number, 51 were successfully transported to the PHC facilities, 46 were successfully treated at the PHC, and five were referred to higher-level care facilities. No maternal deaths occurred during the period, while four perinatal deaths were recorded. CONCLUSION: We conclude that a rapid short message sent from a mobile phone to a central server and connected to transport providers and health facility managers is effective in increasing the access of pregnant women to skilled emergency obstetric services in rural Nigeria.

Effects of multifaceted interventions to prevent and manage primary postpartum haemorrhage in referral hospitals: a quasi-experimental study in Nigeria.

INTRODUCTION: Primary postpartum haemorrhage (PPH) is the leading cause of Nigeria's high maternal mortality rate. This study investigated the effectiveness of a set of multifaceted interventions to manage and reduce PPH in selected secondary referral health facilities in Nigeria. METHODS: This is a quasi-experimental study using an interrupted time-series design to assess a set of multifaceted interventions that address factors identified by stakeholders as associated with PPH. Interventions were implemented at two regional general hospitals, with a general hospital in the same region as the control. Intervention participants were women during antepartum and clinical and administrative staff. Cases of PPH were determined in women at delivery. The outcomes measured were the incidence of primary PPH and related deaths during the study period. Analyses included a comparative description of characteristics of the women, trend of time-series data at intervention and control hospitals, and multivariable analysis of factors associated with PPH occurrence. RESULTS: Monthly numbers of primary PPH were collected at participating hospitals over 21 months for 18 181 women. Intervention hospitals represent 54% vs 46% in control hospitals. Time-series analyses show a significant downward trend in intervention hospitals. The overall incidence of primary PPH was lower in the intervention hospitals than in the control hospitals. Multilevel regression adjusted for hospital-level effect showed a 68% reduction in odds of PPH cases at intervention compared with control hospitals. There were 12 PPH-related maternal deaths in one of the control hospitals, with no deaths in the intervention hospitals. CONCLUSION: We conclude that multiple interventions that address identified challenges in the prevention of primary PPH can potentially effectively reduce reported primary PPH in Nigerian referral hospitals. This approach is relevant for scaling the development of policies and programmes to prevent primary PPH and maternal mortality in Nigeria.

Effect of a multifaceted intervention on the utilisation of primary health for maternal and child health care in rural Nigeria: a quasi-experimental study.

OBJECTIVE: The objective of this study was to determine the effectiveness of a set of multifaceted interventions designed to increase the access of rural women to antenatal, intrapartum, postpartum and childhood immunisation services offered in primary healthcare facilities. DESIGN: The study was a separate sample pretest-post-test quasi-experimental research. SETTING: The research was conducted in 20 communities and primary health centres in Esan South East and Etsako East Local Government Areas in Edo State in southern Nigeria PARTICIPANTS: Randomly selected sample of ever married women aged 15-45 years. INTERVENTIONS: Seven community-led interventions implemented over 27 months, consisting of a community health fund, engagement of transport owners on emergency transport of pregnant women to primary health centres with the use of rapid short message service (SMS), drug revolving fund, community education, advocacy, retraining of health workers and provision of basic equipment. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome measures included the number of women who used the primary health centres for skilled pregnancy care and immunisation of children aged 0-23 months. RESULTS: After adjusting for clustering and confounding variables, the odds of using the project primary healthcare centres for the four outcomes were significantly higher at endline compared with baseline: antenatal care (OR 3.87, CI 2.84 to 5.26 p<0.001), delivery care (OR 3.88, CI 2.86 to 5.26), postnatal care (OR 3.66, CI 2.58 to 5.18) and childhood immunisation (OR 2.87, CI 1.90 to 4.33). However, a few women still reported that the cost of services and gender-related issues were reasons for non-use after the intervention. CONCLUSION: We conclude that community-led interventions that address the specific concerns of women related to the bottlenecks they experience in accessing care in primary health centres are effective in increasing demand for skilled pregnancy and childcare in rural Nigeria.

Why women utilize traditional rather than skilled birth attendants for maternity care in rural Nigeria: Implications for policies and programs.

OBJECTIVE: Data from the Nigeria Demographic and Health Survey indicate that many pregnant women in rural Nigeria use traditional birth attendants (TBAs) rather than skilled birth attendants (SBAs) for maternal health care. This is one factor that accounts for the persistently high rate of maternal mortality in Nigeria. The objective of this study was to identify the pervading reasons that women use TBAs for pregnancy care in rural Nigeria and to make recommendations for policy and programmatic reform. DESIGN: Qualitative research design consisting of focus group discussions, key informant interviews, and community conversations, followed by inductive thematic analysis. SETTING: Twenty rural communities (villages) in Etsako East, and Esan South East Local Government Areas of Edo State, South-South, Nigeria. PARTICIPANTS: Twenty focus group discussions with men and women in a marital union; 15 key informant interviews with policymakers, senior health providers, and women leaders; and 10 community conversations with key community leaders. FINDINGS: Some reasons proffered for using TBAs included perceptions of higher efficacy of traditional medicines; age-long cultural practices; ease of access to TBAs as compared to SBAs; higher costs of services in health facilities; and friendly attitude of TBAs. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The continued use of TBA is a major challenge in efforts to achieve the Sustainable Development Goal 3 in Nigeria. We conclude that efforts to address the factors identified by community stakeholders as inhibiting the use of SBAs will promote skilled birth attendance and reduce maternal mortality in rural Nigeria.

"We have either obsolete knowledge, obsolete equipment or obsolete skills": policy-makers and clinical managers' views on maternal health delivery in rural Nigeria.

OBJECTIVE: The objective of this paper is to explore policy-makers and clinical managers' views on maternal health service delivery in rural Nigeria. DESIGN: This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery. SETTING: The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria. PARTICIPANTS: The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter. RESULTS: Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints. CONCLUSION: This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.

Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria.

BACKGROUND: The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country's very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women's access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women's use of skilled pregnancy care in rural Edo State, Nigeria. METHODS: This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches. RESULTS: Stakeholders identified barriers to pregnant women's use of skilled pregnancy care and they include; financial constraints, women's lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women's use of skilled pregnancy care. CONCLUSIONS: This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women's health behaviour. Therefore, initiatives seeking to improve pregnant women's use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.

Outcomes of a multifaceted intervention to improve maternal satisfaction with care in secondary hospitals in Nigeria.

Background: Data in Nigeria suggests a high level of dissatisfaction among women attending maternity care in health facilities due to long wait times, disrespectful care, and poor attention by healthcare personnel. Objective: To examine the effectiveness of a multifaceted intervention in improving self-reported indicators of maternal healthcare satisfaction by women who use referral facilities in two regions of Nigeria. Method: The design was quasi-experimental and consisted of two intervention facilities and two control facilities. The interventions included strategic planning, staff re-training, a computerized appointment system, health education/feedback, maternal death reviews and surveillance, and advocacy. A random sample of 2262 women was selected (1205 in the intervention sites and 1057 in the two control sites) to respond to a 24-item questionnaire on service satisfaction as they exited the health facilities. Adjusted Poisson and binary regression analyses were used to assess and compare proportions of reported satisfaction by women between the intervention and control sites. Results: Women in the intervention sites were 54% more likely than those in control sites to report overall satisfaction with services. They were significantly less likely to report inadequate security arrangements in accessing the health facilities (p < .1); and three times more likely to agree that health workers were extremely thorough and careful in attending to them (p < .1). Conclusion: The interventions had positive effects on improving women's satisfaction with care. The findings from this study have implications for the design and implementation of interventions that address women's concerns relating to the provision of care and consequently improve service utilization.

Outcome of multifaceted interventions for improving the quality of antenatal care in Nigerian referral hospitals.

BACKGROUND: The study was designed as quasi-experimental research to investigate the effectiveness of multifaceted interventions for improving the quality of antenatal care in referral hospitals in Nigeria. Two referral hospitals (the Central Hospital in Benin City, South-South Nigeria, and the General Hospital in Minna) served as intervention sites, while two hospitals in comparable locations, (the Central Hospital Warri and the Suleja Hospital Abuja) were the control hospitals. METHODS: Intervention activities consisted of the introduction of a strategic plan with the shared vision of reducing maternal mortality by 50% in 1 year in the hospitals; staff training and re-training; the establishment of an automated appointment system; composite health education involving couples and providers; advocacy with policymakers; and the implementation of maternal death reviews and surveillance. These activities were implemented in the intervention hospitals over 21 months (October 2017 to June 2019). Exit interviews of pregnant women at intervention and control sites by trained interviewers were used to assess the quality of antenatal care after their visit, A total of 777 women were interviewed (427 in the intervention sites and 350 in the control sites). Data were analyzed with univariate and multivariate Poisson and logistic regression to determine the extent to which health providers in the clinics completed the 18 signal functions identified in the WHO assessment tool. RESULTS: The regression analyses showed the interventions were effective in improving six quality indicators (QIs) for counseling and information sharing. The difference between intervention and control sites on these QIs was significant at < 0.05. On the contrary, the interventions were less effective for maternal and fetal measurements; and disease testing and management QIs. CONCLUSION: The positive effects of the interventions are likely due to the effectiveness of the training and health education components. The lack of intervention impact observed for maternal and fetal measurements may be due to the high workload of care staff and inadequate clinic supplies, which we did not address. We conclude that interventions that address the quality of antenatal care in low-resource settings should focus on improving all elements of care, including adequate staffing and mobilization of material resources. TRIAL REGISTRATION: This study was registered in the ISRCTN on August 14th, 2020. TRIAL REGISTRATION NUMBER: SRCTN17985403 . Retrospective registration. The reason for the retrospective registration is the current non-recognition of the Nigeria Clinical Trials Registry (NCTR); which is currently not an ICMJE or WHO ICTRP approved registry. (This study was registered in the Nigeria Clinical Trials Registry on April 14th, 2016. Trial Registration Number NCTR No: 91540209 ).

Why rural women do not use primary health centres for pregnancy care: evidence from a qualitative study in Nigeria.

BACKGROUND: While Primary Health Care has been designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths in Nigeria, available evidence suggests that pregnant women in rural communities often do not use Primary Health Care Centres for skilled care. The objective of this study was to investigate the reasons why women do not use PHC for skilled pregnancy care in rural Nigeria. METHODS: Qualitative data were obtained from twenty focus group discussions conducted with women and men in marital union to elicit their perceptions about utilisation of maternal and child health care services in PHC centres. Groups were constituted along the focus of sex and age. The group discussions were tape-recorded, transcribed verbatim and analyzed thematically. RESULTS: The four broad categories of reasons for non-use identified in the study were: 1) accessibility factors - poor roads, difficulty with transportation, long distances, and facility not always open; 2) perceptions relating to poor quality of care, including inadequate drugs and consumables, abusive care by health providers, providers not in sufficient numbers and not always available in the facilities, long waiting times, and inappropriate referrals; 3) high costs of services, which include the inability to pay for services even when costs are not excessive, and the introduction of informal payments by staff; and 4) Other comprising partner support and misinterpretation of signs of pregnancy complications. CONCLUSION: Addressing these factors through adequate budgetary provisions, programs to reduce out-of-pocket expenses for maternal health, adequate staffing and training, innovative methods of transportation and male involvement are critical in efforts to improve rural women's access to skilled pregnancy care in primary health care centres in the country.

Maternal death review and outcomes: An assessment in Lagos State, Nigeria.

The objective of the study was to investigate the results of Maternal and Perinatal Death Surveillance and Response (MPDSR) conducted in three referral hospitals in Lagos State, Nigeria over a two-year period and to report the outcomes and the lessons learned. MPDRS panels were constituted in the three hospitals, and beginning from January 2015, we conducted monthly MPDSR in the three hospitals using a nationally approved protocol. Data on births and deaths and causes of deaths as identified by the MPDSR panels were collated in the hospitals. The results show that over a 21-month period (January 1, 2015 -September 30, 2016), maternal mortality ratio (MMR) remained high in the hospitals. Although there was a trend towards an increase in MMR in Lagos Island Maternity Hospital and Gbagada General Hospital, and a trend towards a decline in Ajeromi Hospital, none of these trends were statistically significant. Eclampsia, primary post-partum haemorrhage, obstructed labour and puerperal sepsis were the leading obstetric causes of death. By contrast, delay in arrival in hospital, the lack of antenatal care and patients' refusal to receive recommended treatment were the patients' associated causes of death, while delay in treatment, poor use of treatment protocols, lack of equipment and lack of skills by providers to use available equipment were the identified facility-related causes of death. Failure to address the patients and facility-related causes of maternal mortality possibly accounted for the persistently high maternal mortality ratio in the hospitals. We conclude that interventions aimed at redressing all causes of maternal deaths identified in the reviews will likely reduce the maternal mortality ratios in the hospitals.