Influence of women's empowerment indices on the utilization of skilled maternity care: evidence from rural Nigeria.

There is increasing evidence that women with the ability to exercise control over their sexual and reproductive lives have greater access to prompt prevention and treatment of maternal health disorders, resulting in a concomitant reduction in maternal morbidity and mortality. This study assessed the association between indices of women's empowerment and utilization of skilled antenatal, intrapartum and postnatal maternity care in two rural Local Government Areas in Edo State, Nigeria. Data were taken from a household survey conducted in July and August 2017, and the study sample comprised 1245 ever-married women currently in a union who had given birth in the 5 years preceding the survey. A Gender Roles Framework guided the selection of independent women's empowerment variables. Using hierarchical logistic regression, the likelihood of receiving all three levels of skilled maternal health care service (antenatal, intrapartum and postnatal) by women's empowerment variables, grouped into resource, decision-making and influencer domains following the model of Anderson and Neuman, was assessed. Of the resource domain variables, respondent's education and respondent's participation in payment for their own health care positively predicted their use of all three levels of skilled maternal care, whereas their ownership of land negatively predicted this. Two decision-making domain variables were significantly associated with respondent's use of all three levels of service: those who made decisions alone about major household purchases were twice as likely to use all three levels of services than when decisions were made by their partners or others, while respondent making decisions alone about what food to cook each day was a negative predictor. Of the influencer variables, religion and a large spousal education gap were strong positive factors, whereas living in a consensual union rather than being legally married was a negative factor. Although health system factors are important, interventions geared towards changing gender norms that constrain women's empowerment are critical to achieving maternal health-related development goals in Nigeria. A composite strategy that targets all women's empowerment indices is recommended, as Nigeria strives towards achieving SDG-3.

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.

Prevalence and determinants of stillbirth in Nigerian referral hospitals: a multicentre study.

BACKGROUND: In 2015, Nigeria's estimated 317,700 stillbirths accounted for 12.2% of the 2.6 million estimated global stillbirths. This suggests that Nigeria still makes substantial contribution to the global burden of stillbirths. This study was conducted to determine the prevalence and identify the causes and factors associated with stillbirth in eight referral hospitals in Nigeria. METHODS: This was a cross-sectional study of all deliveries over a period of 6 months in six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the north) in Nigeria. The study population was women delivering in the hospitals during the study period. A pre-tested study protocol was used to obtain clinical data on pregnancies, live births and stillbirths in the hospitals over a 6 months period. Data were analyzed centrally using univariate, bivariate and multivariate logistic regression analyses. The main outcome measure was stillbirth rate in the hospitals (individually and overall). RESULTS: There were 4416 single births and 175 stillbirths, and a mean stillbirth rate of 39.6 per 1000 births (range: 12.7 to 67.3/1000 births) in the hospitals. Antepartum (macerated) constituted 22.3% of the stillbirths; 47.4% were intrapartum (fresh stillbirths); while 30.3% was unclassified. Acute hypoxia accounted for 32.6% of the stillbirths. Other causes were maternal hypertensive disease (6.9%), and intrapartum unexplained (5.7%) among others. After adjusting for confounding variables, significant predictors of stillbirth were referral status, parity, past experience of stillbirth, birth weight, gestational age at delivery and mode of delivery. CONCLUSION: We conclude that the rate of stillbirth is high in Nigeria's referral hospitals largely because of patients' related factors and the high rates of pregnancy complications. Efforts to address these factors through improved patients' education and emergency obstetric care would reduce the rate of stillbirth in the country. TRIAL REGISTRATION: Trial Registration Number NCTR91540209. Nigeria Clinical Trials Registry. http://www.nctr.nhrec.net/ Registered April 14th 2016.

Examining the Role of Couples' Characteristics in Contraceptive use in Nigeria and Zambia.

Relationship-related characteristics influence diverse health and demographic outcomes. This study examined the role of couples' characteristics in contraceptive use. Data were obtained from 2013 Nigeria and 2013-14 Zambia Demographic and Health Surveys. The study population consisted of couples in monogamous union (married or living together) who had at least one live birth and the wife was not pregnant at the time of the survey. Prevalence of contraceptive use among couples in Nigeria was 27% and 63% in Zambia. Couples' educational attainment, religious affiliation, the frequency of listening to the radio, reported number of children, fertility preference, region of residence and household wealth index were significant predictors of contraceptive use among couples in Nigeria and Zambia. Given the significant role of couples' characteristics in the uptake of contraceptives, there is the need to encourage interventions that target couples, particularly those of poor socioeconomic status.

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.

Comparing the timeliness and adequacy of antenatal care uptake between women who married as child brides and adult brides in 20 sub-Saharan African countries.

CONTEXT: Considering the persistent poor maternal and child health outcomes in sub-Saharan Africa (SSA), this study undertook a comparative analysis of the timing and adequacy of antenatal care uptake between women (aged 20-24 years) who married before age 18 and those who married at age 18 or above. METHOD: Data came from Demographic and Health Surveys of 20 SSA countries. We performed binary logistic regression analysis on pooled data of women aged 20-24 (n = 33,630). RESULTS: Overall, the percentage of child brides in selected countries was 57.1%, with the lowest prevalence found in Rwanda (19.1%) and the highest rate in Chad (80.9%). Central and West African countries had the highest prevalence of child marriage compared to other sub-regions. Bivariate results indicate that a lower proportion of child brides (50.0%) had 4+ ANC visits compared to the adult brides (60.9%) and a lower percentage of them (34.0%) initiated ANC visits early compared to the adult brides (37.5%). After controlling for country of residence and selected socio-economic and demographic characteristics, multivariable results established significantly lower odds of having an adequate/prescribed number of ANC visits among women who married before age 15 (OR: 0.63, CI: 0.57-0.67, p<0.001), and women who married at ages 15-17 (OR: 0.81, CI: 0.75-0.84, p<0.001) compared to those who married at age 18+. Similar results were established between age at first marriage and timing of first ANC visit. Other interesting results emerged that young women who married earlier than age 18 and those who married at age 18+ differ significantly by several socio-economic and demographic characteristics. CONCLUSION: Efforts to improve maternal and child health outcomes in SSA must give attention to address the underutilization and late start of antenatal care uptake among child brides.

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.