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.

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 .

Effect of Volunteer Household Counseling in Improving Knowledge of Birth Preparedness and Complication Readiness of Pregnant Women in Northwest Nigeria.

Maternal and Child Health Integrated Program (MCHIP), a program by Jhpiego global, implemented maternal and newborn health project between 2006 and 2010 in Kano and Zamfara States, Nigeria. This was evaluated with an objective to characterize the effects of volunteer household counselors (VHCs) upon improving knowledge of birth preparedness and complication readiness (BPCR) among pregnant women. VHCs were trained to educate women and their families at home about BPCR. Knowledge of BPCR was compared among 152 and 594 women who did and did not receive household counseling. Mothers' knowledge of BPCR among those who did and did not receive counseling was 32.2% and 11.2% respectively. Mothers who received counseling had better knowledge of BPCR compared to women who did not (Relative Risk [R.R.] 2.30, 95% [C.I.] 1.50, 3.51, P = 0.0001) in a multivariable logistic regression model adjusting for potential confounders. Mothers who received counseling had better odds of knowledge of danger signs during delivery (R.R. 1.48, 95% C.I. 1.05, 2.09, P = 0.02), and post-partum period (R.R. 1.69, 95% C.I. 1.22, 2.32, P = 0.001), but not during pregnancy (R.R. 1.26, 95% C.I. 0.97, 1.64, P = 0.08), compared with women who received no counseling. VHCs can substantially increase knowledge of BPCR and danger signs among women in Nigeria.

Advance distribution of misoprostol for prevention of postpartum hemorrhage (PPH) at home births in two districts of Liberia.

BACKGROUND: A postpartum hemorrhage prevention program to increase uterotonic coverage for home and facility births was introduced in two districts of Liberia. Advance distribution of misoprostol was offered during antenatal care (ANC) and home visits. Feasibility, acceptability, effectiveness of distribution mechanisms and uterotonic coverage were evaluated. METHODS: Eight facilities were strengthened to provide PPH prevention with oxytocin, PPH management and advance distribution of misoprostol during ANC. Trained traditional midwives (TTMs) as volunteer community health workers (CHWs) provided education to pregnant women, and district reproductive health supervisors (DRHSs) distributed misoprostol during home visits. Data were collected through facility and DRHS registers. Postpartum interviews were conducted with a sample of 550 women who received advance distribution of misoprostol on place of delivery, knowledge, misoprostol use, and satisfaction. RESULTS: There were 1826 estimated deliveries during the seven-month implementation period. A total of 980 women (53.7%) were enrolled and provided misoprostol, primarily through ANC (78.2%). Uterotonic coverage rate of all deliveries was 53.5%, based on 97.7% oxytocin use at recorded facility vaginal births and 24.9% misoprostol use at home births. Among 550 women interviewed postpartum, 87.7% of those who received misoprostol and had a home birth took the drug. Sixty-three percent (63.0%) took it at the correct time, and 54.0% experienced at least one minor side effect. No serious adverse events reported among enrolled women. Facility-based deliveries appeared to increase during the program. CONCLUSIONS: The program was moderately effective at achieving high uterotonic coverage of all births. Coverage of home births was low despite the use of two channels of advance distribution of misoprostol. Although ANC reached a greater proportion of women in late pregnancy than home visits, 46.3% of expected deliveries did not receive education or advance distribution of misoprostol. A revised community-based strategy is needed to increase advance distribution rates and misoprostol coverage rates for home births. Misoprostol for PPH prevention appears acceptable to women in Liberia. Correct timing of misoprostol self-administration needs improved emphasis during counseling and education.

Preventing malaria in pregnancy through community-directed interventions: evidence from Akwa Ibom State, Nigeria.

BACKGROUND: Despite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The slow uptake of malaria prevention products appears to reflect lack of knowledge and resistance to behavioural change, as well as poor access to resources, and limited support of programmes by local communities and authorities. METHODS: A recent community-based programme in Akwa Ibom State, Nigeria, is analysed to determine the degree to which community-directed interventions can improve access to malaria prevention in pregnancy. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and kindred in the treatment areas and trained to deliver ITNs and IPTp drugs as well as basic counseling services to pregnant women. FINDINGS: Relative to women in the control area, an additional 7.4 percent of women slept under a net during pregnancy in the treatment areas (95% CI [0.035, 0.115], p-value < 0.01), and an additional 8.5 percent of women slept under an ITN after delivery and prior to the interview (95% CI [0.045, 0.122], p-value < 0.001). The effects of the CDI programme were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p-value < 0.001) relative to the control group. No effects on antenatal care attendance were found. CONCLUSION: The presented results suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions. Given the relatively modest financial commitments they require, community-directed programmes appear to be a cost-effective way to improve malaria prevention; the participatory approach underlying CDI programmes also promises to strengthen ties between the formal health sector and local communities.

Effect of volunteer household counseling in improving knowledge of birth preparedness and complication readiness of pregnant women in northwest Nigeria

Maternal and Child Health Integrated Program (MCHIP), a program by Jhpiego global, implemented maternal and newborn health project between 2006 and 2010 in Kano and Zamfara States, Nigeria. This was evaluated with an objective to characterize the effects of volunteer household counselors (VHCs) upon improving knowledge of birth preparedness and complication readiness (BPCR) among pregnant women. VHCs were trained to educate women and their families at home about BPCR. Knowledge of BPCR was compared among 152 and 594 women who did and did not receive household counseling. Mothers' knowledge of BPCR among those who did and did not receive counseling was 32.2% and 11.2% respectively. Mothers who received counseling had better knowledge of BPCR compared to women who did not (Relative Risk [R.R.] 2.30, 95% [C.I.] 1.50, 3.51, P = 0.0001) in a multivariable logistic regression model adjusting for potential confounders. Mothers who received counseling had better odds of knowledge of danger signs during delivery (R.R. 1.48, 95% C.I. 1.05, 2.09, P = 0.02), and post-partum period (R.R. 1.69, 95% C.I. 1.22, 2.32, P = 0.001), but not during pregnancy (R.R. 1.26, 95% C.I. 0.97, 1.64, P = 0.08), compared with women who received no counseling. VHCs can substantially increase knowledge of BPCR and danger signs among women in Nigeria

Prevalence of and factors associated with extramarital sex among Nigerian men.

This study used data on currently married and cohabiting men aged 15 to 64 years from the 2003 Nigeria Demographic and Health Survey to examine the prevalence of and factors associated with extramarital sex. The results show that 16% engaged in extramarital sex in the 12 months preceding the survey and had an average of 1.82 partners. The results also show statistically significant association between extramarital sex and ethnicity, religion, age, age at sexual debut, education, occupation, and place of residence. Based on the study results, it could be concluded that significant proportions of Nigerians are exposed to HIV infection through extramarital sex. A fundamental behavioral change expected in the era of HIV/AIDS is the inculcation of marital fidelity and emotional bonding between marital partners. The promotion of condom use among married couples should be intensified to protect women, a large number of whom are exposed to HIV infection from their spouses who engage in unprotected extramarital sex. And, because of gender-based power imbalances within the family, a large number of the women are unable to negotiate consistent condom use by their partners.

Knowledge of possible pregnancy at first coitus: a study of in-school adolescents in Ibadan, Nigeria.

This paper discusses the reproductive health knowledge of Nigerian in-school adolescents, with special reference to pregnancy occurrence at first coitus. The data were derived from an Association for Reproductive and Family Health (ARFH) survey carried out in four secondary schools in Ibadan, Nigeria, between August and October 1995. A total of 828 students were interviewed. The results revealed that the majority of sexually active adolescents were not aware of the consequences of their actions. Religious affiliation and number of wives in a male adolescent's family, and religion and marital status of a female adolescent's parents, were found to influence adolescents' knowledge of pregnancy probability at first coitus. This paper confirms earlier findings that the majority of Nigerian adolescents do not know the consequences of sex. Therefore, a clear-cut plan of action is needed to inform sexually active adolescents through an effective sex education programme.

Factors affecting ever-married men's contraceptive knowledge and use in Nigeria.

African men play important roles in the decisions about family life, including fertility and family planning. However, fertility and family planning research and programmes have ignored their roles in the past, focusing only on women's behaviours. Since the 1994 International Conference on Population and Development (ICPD), interest in men's involvement in reproductive health has increased. Unfortunately, data on their knowledge and use of contraception are generally scanty. This paper examines knowledge and use of contraception among ever-married men in Nigeria. A total of 1451 ever-married men aged 18-55 were interviewed in Imo and Ondo States, Nigeria. The findings reveal that men's level of contraceptive knowledge is high in the study areas. About 90% knew at least one method of family planning. Furthermore, the level of contraceptive use among married men is such that men could participate in family planning activities if there were adequate programmes to involve them. Men in the sample areas were found not only to support their spouses' use of contraceptives, but were actually using condoms to delay or prevent pregnancy. Age, education, place of residence, number of living children and being counselled for family planning were identified as key factors determining contraceptive knowledge and use among married men in the study areas. To ensure increased participation of men in family planning, programmes must be designed to educate them on the need for family size limitation and involve them in service delivery, even if only to their male counterparts.