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 ).

Assessing the knowledge and skills on emergency obstetric care among health providers: Implications for health systems strengthening in Nigeria.

OBJECTIVE: To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria. STUDY DESIGN: A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period. SETTING: Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country. POPULATION: All skilled providers offering EMOC services in the hospitals during the study. METHODS: A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents' knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall. RESULTS: A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores. CONCLUSION: The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country. TRIAL REGISTRATION: Nigeria Clinical Trials Registry 91540209.

Where do delays occur when women receive antenatal care? A client flow multi-site study in four health facilities in Nigeria.

OBJECTIVES: The objective of the study was to identify where delays occur when women present for antenatal care in four Nigerian referral hospitals, and to make recommendations on ways to reduce delays in the course of provision of antenatal care in the hospitals. DESIGN: Prospective observational study. SETTING: Four Nigerian (1 tertiary and 3 secondary) Hospitals. PARTICIPANTS: Women who presented for antenatal care. INTERVENTIONS: A process mapping. The National Health Service (NHS) Institute Quality and Service Improvement Tool was used for the assessment. MAIN OUTCOME MEASURES: The time women spent in waiting and receiving antenatal care in various departments of the hospitals. RESULTS: Waiting and total times spent varied significantly within and between the hospitals surveyed. Mean waiting and total times spent were longest in the outpatients' departments and shortest in the Pharmacy Departments. Total time spent was an average of 237.6 minutes. χ2= 21.074; p= 0.0001. CONCLUSION: There was substantial delay in time spent to receive care by women seeking routine antenatal health services in the four secondary and tertiary care hospitals. We recommend managers in health facilities include the reduction of waiting times in the strategic plans for improving the quality of antenatal care in the hospitals. This should include the use of innovative payment systems that excludes payment at time of service delivery, adoption of a fast-track system such as pre-packing of frequently used commodities and the use of new tech informational materials for the provision of health education. FUNDING: The Alliance for Health Policy and Systems Research, World Health Organization, Geneva; Protocol ID A65869.

Prevalence and risk factors for maternal mortality in referral hospitals in Nigeria: a multicenter study.

INTRODUCTION: While reports from individual hospitals have helped to provide insights into the causes of maternal mortality in low-income countries, they are often limited for policymaking at national and subnational levels. This multisite study was designed to determine maternal mortality ratios (MMRs) and identify the risk factors for maternal deaths in referral health facilities in Nigeria. METHODS: A pretested study protocol was used over a 6-month period (January 1-June 30, 2014) to obtain clinical data on pregnancies, births, and maternal deaths in eight referral hospitals across eight states and four geopolitical zones of Nigeria. Data were analyzed centrally using univariate, bivariate, and multivariate statistics. RESULTS: The results show an MMR of 2,085 per 100,000 live births in the hospitals (range: 877-4,210 per 100,000 births). Several covariates were identified as increasing the odds for maternal mortality; however, after adjustment for confounding, five factors remained significant in the logistic regression model. These include delivery in a secondary health facility as opposed to delivery in a tertiary hospital, non-booking for antenatal and delivery care, referral as obstetric emergency from nonhospital sources of care, previous experience by women of early pregnancy complications, and grandmultiparity. CONCLUSION: MMR remains high in referral health facilities in Nigeria due to institutional and patient-related factors. Efforts to reduce MMR in these health facilities should include the improvement of emergency obstetric care, public health education so that women can seek appropriate and immediate evidence-based pregnancy care, the socioeconomic empowerment of women, and the strengthening of the health care system.

Association of the client-provider ratio with the risk of maternal mortality in referral hospitals: a multi-site study in Nigeria.

BACKGROUND: The paucity of human resources for health buoyed by excessive workloads has been identified as being responsible for poor quality obstetric care, which leads to high maternal mortality in Nigeria. While there is anecdotal and qualitative research to support this observation, limited quantitative studies have been conducted to test the association between the number and density of human resources and risk of maternal mortality. This study aims to investigate the association between client-provider ratios for antenatal and delivery care and the risk of maternal mortality in 8 referral hospitals in Nigeria. METHODS: Client-provider ratios were calculated for antenatal and delivery care attendees during a 3-year period (2011-2013). The maternal mortality ratio (MMR) was calculated per 100,000 live births for the hospitals, while unadjusted Poisson regression analysis was used to examine the association between the number of maternal deaths and density of healthcare providers. RESULTS: A total of 334,425 antenatal care attendees and 26,479 births were recorded during this period. The client-provider ratio in the maternity department for antenatal care attendees was 1343:1 for doctors and 222:1 for midwives. The ratio of births to one doctor in the maternity department was 106:1 and 18:1 for midwives. On average, there were 441 births per specialist obstetrician. The results of the regression analysis showed a significant negative association between the number of maternal deaths and client-provider ratios in all categories. CONCLUSION: We conclude that the maternal mortality ratios in Nigeria's referral hospitals are worsened by high client-provider ratios, with few providers attending a large number of pregnant women. Efforts to improve the density and quality of maternal healthcare providers, especially at the first referral level, would be a critical intervention for reducing the currently high rate of maternal mortality in Nigeria. TRIAL REGISTRATION: Trial Registration Number: NCTR91540209 . Nigeria Clinical Trials Registry. Registered 14 April 2016.

Views of senior health personnel about quality of emergency obstetric care: A qualitative study in Nigeria.

BACKGROUND: Late arrival in hospital by women experiencing pregnancy complications is an important background factor leading to maternal mortality in Nigeria. The use of effective and timely emergency obstetric care determines whether women survive or die, or become near-miss cases. Healthcare managers have the responsibility to deploy resources for implementing emergency obstetric care. OBJECTIVES: To determine the nature of institutional policies and frameworks for managing obstetric complications and reducing maternal deaths in Nigeria. METHODS: Thirty-six hospital managers, heads of obstetrics department and senior midwives were interviewed about hospital infrastructure, resources, policies and processes relating to emergency obstetric care, whilst allowing informants to discuss their thoughts and feelings. The interviews were audiotaped, transcribed and analyzed using Atlas ti 6.2software. RESULTS: Hospital managers are aware of the seriousness of maternal mortality and the steps to improve maternal healthcare. Many reported the lack of policies and specific action-plans for maternal mortality prevention, and many did not purposely disburse budgets or resources to address the problem. Although some reported that maternal/perinatal audit take place in their hospitals, there was no substantive evidence and no records of maternal/perinatal audits were made available. Respondents decried the lack of appropriate data collection system in the hospitals for accurate monitoring of maternal mortality and identification of appropriate remediating actions. CONCLUSION: Healthcare managers are handicapped to properly manage the healthcare system for maternal mortality prevention. Relevant training of healthcare managers would be crucial to enable the development of strategic implementation plans for the prevention of maternal mortality.

Qualitative assessment of women's satisfaction with maternal health care in referral hospitals in Nigeria.

BACKGROUND: Available evidence suggests that the low use of antenatal, delivery, and post-natal services by Nigerian women may be due to their perceptions of low quality of care in health facilities. This study investigated the perceptions of women regarding their satisfaction with the maternity services offered in secondary and tertiary hospitals in Nigeria. METHODS: Five focus group discussions (FGDs) were held with women in eight secondary and tertiary hospitals in four of the six geo-political zones of the country. In all, 40 FGDs were held with women attending antenatal and post-natal clinics in the hospitals. The questions assessed women's level of satisfaction with the care they received in the hospitals, their views on what needed to be done to improve patients' satisfaction, and the overall quality of maternity services in the hospitals. The discussions were audio-taped, transcribed, and analyzed by themes using Atlas ti computer software. RESULTS: Few of the participants expressed satisfaction with the quality of care they received during antenatal, intrapartum, and postnatal care. Many had areas of dissatisfaction, or were not satisfied at all with the quality of care. Reasons for dissatisfaction included poor staff attitude, long waiting time, poor attention to women in labour, high cost of services, and sub-standard facilities. These sources of dissatisfaction were given as the reasons why women often preferred traditional rather than modern facility based maternity care. The recommendations they made for improving maternity care were also consistent with their perceptions of the gaps and inadequacies. These included the improvement of hospital facilities, re-organization of services to eliminate delays, the training and re-training of health workers, and feedback/counseling and education of women. CONCLUSION: A women-friendly approach to delivery of maternal health care based on adequate response to women's concerns and experiences of health care will be critical to curbing women's dissatisfaction with modern facility based health care, improving access to maternal health, and reducing maternal morbidity and mortality in Nigeria. TRIAL REGISTRATION: Trial Registration Number NCTR No: 91540209. Nigeria Clinical Trials Registry. http://www.nctr.nhrec.net/ . Registered April 14th 2016.