Exploring providers' perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria: A qualitative study

"I went to the primary health centre close to my workplace, but their capacity cannot deliver the baby": exploring why women choose different providers for maternal health services in Nigeria

BACKGROUND

Maternal health remains a significant public health concern globally, including Nigeria. Despite concerted efforts to improve maternal health services, maternal mortality rates in Nigeria remain unacceptably high. Understanding the factors that shape women's choices in selecting the place of birth could help tailor services and improve quality of care for mothers and infants. Therefore, our study explores the experiences, barriers and facilitators that influence where women choose to access maternal health services in three diverse Nigerian states of Lagos, Oyo and Jigawa.

METHODS

We conducted qualitative in-depth interviews with nursing mothers and healthcareworkers (HCWs) in Lagos, Oyo and Jigawa states, and community birth attendants (CBAs) in Lagos and Oyo. We used maximum variation sampling to purposefully recruit nursing mothers in their puerperium who gave birth in different places. HCWs and CBAs were purposively selected from health facilities and birth homes. All interviews were conducted between September - December 2023. We used reflexive thematic analysis to generate themes across participant types and states.

RESULTS

We recruited 44 participants for this study, 25 nursing mothers and 19 HCWs. We identified five major themes: (1) Preference for safe, comfortable and quality health services; (2) Social diffusion and cultural/religious influences; (3) Physical, geographical and financial inaccessibility; (4) Symbolic perception of health facilities and (5) Misunderstanding of health promoting and preventive care in pregnancy. The main reasons for choosing a particular place of birth were the preference for safe, comfortable, and high-quality healthcare, as well as the perceived convenience and accessibility of birth homes within close proximity to the women's homes.

CONCLUSIONS

We found women's choice of place of birth is influenced by a complex interplay of factors. Among these are health system inadequacies, socio-economic factors, and the desire for comfortable and quality maternal healthcare. HCWs, CBAs, and nursing mothers emphasised these determinants as critical in shaping women's decisions regarding where to give birth. This highlights the need for comprehensive interventions across policy, healthcare delivery, community engagement, and individual levels to overcome barriers, improve maternal health outcomes, and support women in making informed childbirth decisions.

Enhancing programmatic scale-up: Applying the consolidated framework for implementation research to evaluate decentralized drug-resistant tuberculosis services in Southern Nigeria

BACKGROUND

Decentralization of Drug-Resistant Tuberculosis (DR-TB) services using multilevel interventions was piloted in Akwa-Ibom and Oyo States of Nigeria, which had high rates of pre-treatment loss-to-follow-up in 2021. The varying outcomes of the intervention strategies necessitated understanding what worked well and why. This study aimed to identify enablers and barriers shaping the implementation of decentralized DR-TB services in these states and provide actionable strategies for programmatic scale-up.

METHODS

Semi-structured key informant interviews were conducted with 40 stakeholders involved in the pilot implementation of decentralized DR-TB services in southern Nigeria. Interviews were audio-recorded, transcribed verbatim, and template analysis done using NVivo statistical software, adapting the Consolidated Framework for Implementation Research (CFIR) constructs and sub-constructs as priori codes for data synthesis and analysis.

RESULTS

The study identified enablers and barriers across the five CFIR domains. Intervention characteristics facilitators stemmed from its relative advantage and design enabling faster notification of diagnosed DR-TB patients, enhanced patient tracking, ease of conducting baseline investigations, bringing treatment closer by reducing transportation challenges, unique role of the Volunteer Liaison Officer, utility of WhatsApp platform, private sector engagement, and DR-TB survivors as peer counsellors. Critical incidents such as the removal of fuel subsidies and economic difficulties; and inner setting factors like existing infrastructure and health workforce, culture, available resources and tension for change from high pre-treatment loss to follow-up, and intervention's alignment with workflow; all facilitated implementation. Barriers identified included: challenges with verbal autopsy, low adoption of Unstructured Supplementary Service Data (USSD) innovation, pricing of baseline tests, poor power supply, inadequate laboratory facilities and insufficient DR-TB expertise in rural areas, and fear of TB infection among health workers.

CONCLUSION

The findings demonstrate the ease of implementing decentralized DR-TB services and their advantages over a centralized approach. Key enablers centered on innovation and individual characteristics, and inner setting dynamics within the TB program. There were more facilitators than barriers, with most barriers being modifiable despite some outer setting factors like fiscal policy and geographic access. These insights can guide nationwide adoption and scale-up of decentralized DR-TB services in Nigeria and similar settings in low-and middle-income countries.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR202309676675265.

Exploring the perspectives of healthcare workers and Program managers on the use of Truenat as a new tool for TB and DR-TB diagnosis in Nigeria: A qualitative study

BACKGROUND

World Health Organization in the year 2020 recommended the use of Truenat as a replacement for smear microscopy in Tuberculosis (TB) diagnosis and detection of rifampicin resistance. This study was designed to assess enablers and barriers to effective implementation of Truenat assays for TB diagnosis in Nigeria and determine the acceptability of use of Truenat among healthcare workers and TB Program managers in Nigeria.

METHODS

A descriptive exploratory study design was used. Qualitative data were collected via Zoom platform using a pre-tested focus group discussion (FGD) guide and key informant interview (KII) guide. Four FGDs were conducted among Truenat laboratory staff, State Quality Assurance Officers, Local Government Tuberculosis Supervisors and Clinicians working at Truenat sites. Three KIIs were conducted among laboratory leads of Truenat implementing partners and the National TB Control Program.

RESULTS

All the participants attested to the reliability and acceptability of Truenat results, they also highlighted the portability and ease-of-use especially for community outreach testing. Stakeholder engagement, training of Truenat laboratory staff and the perceived low operational cost associated with Truenat were the enablers of Truenat implementation. Major barriers to the implementation included human resource for health constraints, lack of power supply, frequent Trueprep breakdown and Truenat machine connectivity. The same human resource constraint was viewed as the major barrier to scale up of Truenat while employment and retention of Truenat staff coupled with training were seen as the facilitators to scale-up. The participants implored the manufacturers of Truenat to increase the number of modules for Truenat, enable the use of stool for diagnosis of TB and attach a solar panel to the machine.

CONCLUSION

Truenat has gained high acceptance among health workers and TB Program managers in Nigeria. The perceived low operational cost and low infrastructural requirements have been a major boost. There is a need to ensure the retention of health workers especially the Truenat laboratory staff. Training should be sustained including the payment of incentives. Increasing the number of modules of the Truenat machine, enabling the use of stool for TB diagnosis and having a solar panel attached to Truenat machine are essential.

Barriers and facilitators to antenatal care services utilisation in Somaliland: a qualitative study

OBJECTIVE

To explore the barriers and facilitators of antenatal care (ANC) utilisation in Somaliland.

DESIGN

An exploratory qualitative study design.

SETTING

Various settings were considered for study including maternal and child health clinics, hospitals and community.

METHODS

74 study participants including 33 pregnant women, 22 healthcare providers, 10 community elders and ten religious leaders were purposively selected. Data was collected via focus group discussion and in-depth interviews in the local Somali language. The data was audio recorded, transcribed verbatim, translated into English and imported into NVivo V.12 software. Thematic framework analysis was used to assess barriers and facilitators of ANC utilisation.

RESULTS

Six main themes were identified as barriers of ANC utilisation. These include lack of awareness, long distance and lack of transportation access, economic barriers, lack of social support, beliefs and thoughts and health facility-related factors such as caregivers approach, waiting time and inadequate skill of providers. Proper dissemination of ANC information, adequate spousal support and cheap pricing of services were found to be facilitators of ANC uptake.

CONCLUSION

A strategy that focuses on raising awareness about ANC, making it accessible by reducing the cost-of-service charge, encouraging partner involvement, improving the quality of services and making it customer-friendly will help to overcome the barriers of antenatal utilisation.

Utilization of Antenatal Care and Skilled Birth Delivery Services in Sub-Saharan Africa: A Systematic Scoping Review

Daily, the number of women who die around the world reaches an average of 800; these deaths are a result of obstetric complications in pregnancy and childbirth, and 99% of these deaths occur in low- and middle-income countries. This review probes the use of antenatal care (ANC) and skilled birth delivery (SBD) services in sub-Saharan Africa (SSA) and highlights research gaps using Arksey and O'Malley's methodological approach. The screening of abstracts and full text was carried out by two independent authors who ensured the eligibility of data extraction from the included articles. An exploration of the data was undertaken with descriptive analyses. In total, 350 potentially eligible articles were screened, and 137 studies were included for data extraction and analysis. From the 137 included studies, the majority were from Ethiopia (n = 40, 29.2%), followed by Nigeria (n = 30, 21.9%). Most of the studies were published between 2019 and 2023 (n = 84, 61%). Significant trends and challenges with ANC and SBD services emerged from the studies. It is revealed that there are wide gaps in the utilization of ANC and SBD services. Policy attention, intervention strategies to improve access, resources, rural-urban disparity, and women's literacy are recommended to improve the utilization of ANC and SBD services in SSA countries.

An investigation of factors affecting the utilization of antenatal care services among women in post-natal wards in two Namibian hospitals in the Khomas region

Background

Antenatal care (ANC) services are the care provided by skilled healthcare professionals to pregnant women to ensure the best health for both mother and baby during pregnancy and after delivery. In Namibia, utilization of antenatal care services has been reported to be dropping from 97% in 2013 to 91% in 2016.

Objectives

The objectives of this study were to investigate the factors affecting the utilization of ANC services.

Methods

A quantitative approach and a cross-sectional analytical design were used to carry out the study. The study population was all mothers who delivered and were admitted to the postnatal ward of Intermediate Hospital Katutura and Windhoek Central Hospital during the time of the study. Data were collected from 320 participants using self-administered structured questionnaires. The data were analyzed using the Statistical Package for Social Science (SPSS) Version 25 software.

Results

Participants were aged between 16 and 42 years with a mean age of 27 years. The results show that 229 (71.6%) utilized ANC while 91(28.4%) did not utilize ANC services. Factors such as the negative attitude of health care workers, long distance to and from health facilities, lack of transport money to travel to and from the health facilities, lack of knowledge regarding antenatal care, attitude towards pregnancy, and others, were found as hindrances to the utilization of antenatal care services. Participants also indicated motivators for ANC utilization such as preventing complications, knowing their HIV status, getting health education, knowing the estimated date of delivery, and identifying and treatment of medical conditions. The study reveals the higher knowledge of participants on ANC utilization, most participants have the right to make decisions and had positive attitudes toward the quality of ANC services. The level of attitude toward pregnancy was associated with the utilization of antenatal care services with an odd ratio OR=2.132; and P=0.014.

Conclusions

The study identified factors that affect utilization of ANC services such as age, marital status, mother's education, partner's formal education, negative attitude toward health providers, long distance to and from ANC health care facilities, fear of HIV test and results, Covid-19 regulations, inability to determine the pregnancy at the earlier stages and financial constraints Based on this study findings, it is recommended that the utilization of ANC might be improved through effective community mobilization and outreach maternity services to educate and improve awareness on the importance of ANC.

Where, why and who delivers our babies? Examining the perspectives of women on utilization of antenatal and delivery services in a developing country

BACKGROUND

The differences in maternal mortality between developed and developing countries is due to differences in use of antenatal and delivery services. The study was designed to determine the views of women on utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria.

METHODS

Community based descriptive exploratory study design was employed. Qualitative data was collected through use of pre-tested focus group discussion (FGD) guide. Eight FGDs were conducted among women who were pregnant and others who have delivered babies one year prior to the study. Four FGDs each were conducted in urban and rural communities. QDA Miner Lite v2.0.6 was used in the analysis of the data.

RESULTS

Most of the participants in urban and rural areas prefer the man and woman deciding on where to receive antenatal and deliver care. All the participants in urban and rural communities wish for the support of their husbands when pregnant. Perceived quality of care is the major reason the women choose a facility for antenatal and delivery services. Others reasons included cost of services and proximity to a facility. Participants in rural communities were of the opinion that traditional birth attendants deliver unique services including helping women to achieve conception. For participants in urban, traditional birth attendants are very friendly and perhaps on divine assignment. These reasons explain why women still patronize their services. The major criticism of services of traditional birth attendants is their inability to manage complications associated with pregnancy and delivery. The major reasons why women delivery at home included poverty and cultural beliefs.

CONCLUSIONS

All efforts should be made to reduce the huge maternal death burden in Nigeria. This may necessitate the involvement of men and by extension communities in antenatal and delivery matters. There is need to train health workers in orthodox health facilities on delivery of quality healthcare. Public enlightenment on importance of health facility delivery will be of essence. Encouraging women to deliver in health facilities should be prioritized. This may entail the provision of free or subsidized delivery services. The deficiencies of primary health centers especially in rural communities should be addressed.

Barriers and facilitators of access to maternal, newborn and child health services during the first wave of COVID-19 pandemic in Nigeria: findings from a qualitative study

BACKGROUND

COVID-19 pandemic may have affected the utilization of maternal and newborn child health services in Nigeria but the extent, directions, contextual factors at all the levels of healthcare service delivery in Nigeria is yet to be fully explored. The objective of the study was to explore the barriers and facilitators of access to MNCH services during the first wave of COVID-19 pandemic in Nigeria.

METHODS

A qualitative study was conducted among different stakeholder groups in 18 public health facilities in Nigeria between May and July,2020. In-depth interviews were conducted among 54 study participants (service users, service providers and policymakers) selected from across the three tiers of public health service delivery system in Nigeria (primary health centers, secondary health centers and tertiary health centers). Coding of the qualitative data and identification of themes from the transcripts were carried out and thematic approach was used for data analyses.

RESULTS

Barriers to accessing MNCH services during the first wave of COVID-19-pandemic in Nigeria include fear of contracting COVID-19 infection at health facilities, transportation difficulties, stigmatization of sick persons, lack of personal protective equipment (PPE) /medical commodities, long waiting times at hospitals, shortage of manpower, lack of preparedness by health workers, and prioritization of essential services. Enablers to access include the COVID-19 non-pharmacological measures instituted at the health facilities, community sensitization on healthcare access during the pandemic, and alternative strategies for administering immunization service at the clinics.

CONCLUSION

Access to MNCH services were negatively affected by lockdown during the first wave of COVID-19 pandemic in Nigeria particularly due to challenges resulting from restrictions in movements which affected patients/healthcare providers ability to reach the hospitals as well as patients' ability to pay for health care services. Additionally, there was fear of contracting COVID-19 infection at health facilities and the health systems inability to provide enabling conditions for sustained utilization of MNCH services. There is need for government to institute alternative measures to halt the spread of diseases instead of lockdowns so as to ensure unhindered access to MNCH services during future pandemics. This may include immediate sensitization of the general public on modes of transmission of any emergent infectious disease as well as training of health workers on emergency preparedness and alternative service delivery models.