What does quality maternity care mean in a context of medical pluralism? Perspectives of women in Nigeria

Understanding gender dynamics in mHealth interventions can enhance the sustainability of benefits of digital technology for maternal healthcare in rural Nigeria

Introduction

Nigeria faces enormous challenges to meet the growing demands for maternal healthcare. This has necessitated the need for digital technologies such as mobile health, to supplement existing maternal healthcare services. However, mobile health programs are tempered with gender blind spots that continue to push women and girls to the margins of society. Failure to address underlying gender inequalities and unintended consequences of mobile health programs limits its benefits and ultimately its sustainability. The importance of understanding existing gender dynamics in mobile health interventions for maternal health cannot be overstated.

Objective

This study explores the gender dimensions of Text4Life, a mobile health intervention for maternal healthcare in Edo State, Nigeria by capturing the unique perspectives of women who are the primary beneficiaries, their spouses who are all men, and community leaders who oversaw the implementation and delivery of the intervention.

Method

This qualitative study used criterion-based purposive sampling to recruit a total of 66 participants: 39 women, 25 men, and two ward development committee chairpersons. Data collection involved 8 age and sex desegregated focus group discussions with women and men and in-depth interviews with ward development committee chairpersons in English or Pidgin English. Translated and transcribed data were exported to NVivo 1.6 and data analysis followed a conventional approach to thematic analysis.

Results

Women had some of the necessary resources to participate in the Text4Life program, but they were generally insufficient thereby derailing their participation. The program enhanced women's status and decision-making capacity but with men positioned as heads of households and major decision-makers in maternal healthcare, there remained the possibility of deprioritizing maternal healthcare. Finally, while Text4Life prioritized women's safety in various contexts, it entrenched systems of power that allow men's control over women's reproductive lives.

Conclusion

As communities across sub-Saharan Africa continue to leverage the use of mHealth for maternal health, this study provides insights into the gender implications of women's use of mHealth technologies. While mHealth programs are helpful to women in many ways, they are not enough on their own to undo entrenched systems of power through which men control women's access to resources and their reproductive and social lives.

Factors that influence uptake of routine postnatal care: Findings on women's perspectives from a qualitative evidence synthesis

BACKGROUND

Effective postnatal care is important for optimal care of women and newborns-to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care.

METHODS

We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach.

FINDINGS

Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women's desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care.

CONCLUSIONS

Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings.

REGISTRATION

This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Exploring underutilization of skilled maternal healthcare in rural Edo, Nigeria: A qualitative study

Introduction

Existing studies have acknowledged the underutilization of skilled maternal healthcare services among women in rural Nigeria. Consequently, women in rural areas face a disproportionate risk of poor health outcomes including maternal morbidity and mortality. Addressing the challenge of non-use of skilled maternal healthcare in rural areas necessitates the involvement of multi-stakeholders across different sectors who have vital roles to play in improving maternal health. This study explores the factors contributing to the non-use of maternal healthcare services in rural areas of Edo, Nigeria from the perspectives of community elders and policymakers.

Methods

In this qualitative study, data were collected through 10 community conversations (group discussions) with community elders each consisting of 12 to 21 participants, and six key informant interviews with policymakers in rural areas of Edo State, Nigeria. Participants were purposefully selected. Conversations and interviews occurred in English, Pidgin English and the local language; lasted for an average of 9 minutes; were audio-recorded and transcribed to English. Data were manually coded, and data analysis followed the analytical strategies for qualitative description including an iterative process of inductive and deductive approaches.

Results

Policymakers and community elders attributed the non-use of maternal health services to poor quality of care. Notions of poor quality of care included shortages in skilled healthcare workers, apathy and abusive behaviours from healthcare providers, lack of life-saving equipment, and lack of safe skilled pregnancy care. Non-use was also attributed to women’s complex utilization patterns which involved a combination of different types of healthcare services, including traditional care. Participants also identified affordability and accessibility factors as deterrents to women’s use of skilled maternal healthcare.

Conclusion

The emerging findings on pregnant women’s combined use of different types of care highlight the need to improve the quality, availability, accessibility, and affordability of skilled maternal care for rural women in Nigeria.

The tipping point of antenatal engagement: A qualitative grounded theory in Tanzania and Zambia

BACKGROUND

Effective antenatal care is fundamental to the promotion of positive maternal and new-born outcomes. International guidance recommends an initial visit in the first trimester of pregnancy, with a minimum of four antenatal visits in total: the optimum schedule being eight antenatal contacts. In low- and middle-income countries, many women do not access antenatal care until later in pregnancy and few have the recommended number of contacts.

AIM

To gain understanding of women's antenatal experiences in Tanzania and Zambia, and the factors that influence antenatal engagement.

METHODS

The study was underpinned by Strauss's grounded theory methodology. Interviews were conducted with 48 women, 16 partners, 21 health care providers and 11 stakeholders, and analysed using constant comparison.

FINDINGS

The core category was 'The tipping point of antenatal engagement', supported by four categories: awareness of health benefits, experiential motivators, influential support, and environmental challenges. Although participants recognised the importance of antenatal care to health outcomes, individual motivations and external influences determined attendance or non-attendance. The 'tipping point' for antenatal engagement occurred when women believed that any negative impact could be offset by tangible gain. For some women non-attendance was a conscious decision, for others it was an unchallenged cultural norm.

CONCLUSION

A complex interplay of factors determines antenatal engagement. Short-term modifiable factors to encourage attendance include the development of strategies for increasing respectful care; use of positive women's narratives, and active community engagement. Further research is required to develop innovative, cost-effective care models that improve health literacy and meet women's needs.

Decomposition of socioeconomic inequalities in the uptake of intermittent preventive treatment of malaria in pregnancy in Nigeria: evidence from Demographic Health Survey

Background

Although malaria in pregnancy is preventable with the use of intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP), it still causes maternal morbidity and mortality, in sub-Saharan Africa and Nigeria in particular. Socioeconomic inequality leads to limited uptake of IPTp-SP by pregnant women and is, therefore, a public health challenge in Nigeria. This study aimed to measure and identify factors explaining socioeconomic inequality in the uptake of IPTp-SP in Nigeria.

Methods

The study re-analysed dataset of 12,294 women aged 15–49 years from 2018 Nigeria Demographic Health Survey (DHS). The normalized concentration index (C_n) and concentration curve were used to quantify and graphically present socioeconomic inequalities in the uptake of IPTp-SP among pregnant women in Nigeria. The C_n was decomposed to identify key factors contributing to the observed socioeconomic inequality in the uptake of adequate (≥ 3) IPTp-SP.

Results

The study showed a higher concentration of the adequate uptake of IPTp-SP among socioeconomically advantaged women (C_n = 0.062; 95% confidence interval [CI] 0.048 to 0.076) in Nigeria. There is a pro-rich inequality in the uptake of IPTp-SP in urban areas (C_n = 0.283; 95%CI 0.279 to 0.288). In contrast, a pro-poor inequality in the uptake of IPTp-SP was observed in rural areas (C_n = − 0.238; 95%CI − 0.242 to − 0.235). The result of the decomposition analysis indicated that geographic zone of residence and antenatal visits were the two main drivers for the concentration of the uptake of IPTp-SP among wealthier pregnant women in Nigeria.

Conclusion

The pro-rich inequalities in the uptake of IPTp-SP among pregnant women in Nigeria, particularly in urban areas, warrant further attention. Strategies to improve the uptake of IPTp-SP among women residing in socioeconomically disadvantaged geographic zones (North-East and North-West) and improving antenatal visits among the poor women may reduce pro-rich inequality in the uptake of IPTp-SP among pregnant women in Nigeria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03834-8.

Abortion quality of care from the client perspective: a qualitative study in India and Kenya

Quality healthcare is a key part of people's right to health and dignity, yet access to high-quality care can be limited by legal, social and economic contexts. There is limited consensus on what domains constitute quality in abortion care and the opinions of people seeking abortion have little representation in current abortion quality measures. In this qualitative study, we conducted 45 interviews with abortion clients in Mumbai, India, and in Eldoret and Thika, Kenya, to assess experiences with abortion care, definitions of quality and priorities for high-quality abortion care. Among the many aspects of care that mattered to clients, the client-provider relationships emerged as essential. Clients prioritized being treated with kindness, respect and dignity; receiving information and counselling that was personalized to their individual situation and reassurance and support from their provider throughout the entire abortion process, including follow-up after the abortion. Many clients also noted the importance of skilled providers and appropriate care. There were similarities across the two country contexts, yet there were some differences in how clients defined high-quality care; therefore, specific political and cultural influences must be considered when implementing measurement and improving person-centred quality of care. These domains, particularly interpersonal interactions, should be prioritized in India and Kenya when health systems, facilities and providers design person-centred measures for quality in abortion care.

Mothers' Experiences and Perceptions of Facility-based Delivery Care in Rural Ethiopia

In Ethiopia, delivery wards are a part of primary healthcare services. However, although the maternal mortality rate is very high, approximately 50% of mothers use skilled birth attendants. This study focused on how women in a rural southern district of Ethiopia experience maternity care offered at the local delivery wards. In this qualitative, exploratory study, 19 women who had given birth in a healthcare facility were interviewed in 2019. Individual in-depth interviews were supplemented with observations conducted at 2 different delivery wards in the same district in 2020. Two main themes emerged from the thematic content analysis: increased awareness and safety were the primary reasons for giving birth at a healthcare facility, and traditions and norms affected women’s birth experiences in public maternity wards. The main shortcomings were a shortage of medicine, ambulance not arriving in time, and lack of care at night. For some women, being assisted by a male midwife could be challenging, and the inability to afford necessary medicine made adequate treatment inaccessible. Providing continuous information gave the women a certain feeling of control. Strong family involvement indicated that collectivistic expectations were key to rural delivery wards. The healthcare system must be structured to meet women’s needs. Moreover, managers and midwives should ensure that birthing women receive high-quality, safe, timely, and respectful care.

Risk factors affecting maternal health outcomes in Rivers State of Nigeria: Towards the PRISMA model

Existing research suggests that Nigeria accounts for about 23% of the world's maternal mortality ratio, with negative impacts on women's wellbeing and the country's socio-economic development. The underlying risk factors can be categorized into political influences, poor access to healthcare, inadequate utilization of health facilities, poor family planning support and complex pregnancy-related illness. Yet, the complex interrelations amongst the factors makes it difficult to ascertain the riskiest ones that affect women's reproduction and child death, with the existing intervening strategies failing to address the problem. This study identifies maternal health risk factors and prioritizes their management in Rivers State of Nigeria, using the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA) model. Taking a quantitative turn, we applied exploratory factor analysis to analyze 174 returned questionnaires from healthcare professionals working in Rivers State and used the results to establish relationships between maternal health risk factors, prioritizing the riskiest factors. The outcomes indicate that the PRISMA model provides an effective framework for identifying and managing maternal mortality risks that can enable healthcare experts and managers to address the avoidable risk factors and mitigate the unavoidable patient-related risk factors in Nigeria. The implications for theory, practice and policy are discussed.

Community Perception Regarding Maternity Service Provision in Public Health Institutions in 2018 and 2019: A Qualitative Study

Background

In the perspective of health care, community perception is defined as a combination of experiences, expectations and perceived needs. The community and client’s perception of health services seem to have been largely ignored by health-care providers in developing countries. There is a knowledge gap about communities’ perception and perspective of maternal health. If the community’s perception is known, the quality of maternity care may be improved, maternal morbidity and mortality could be decreased, and the overall health of the mother can be improved. The aim of this study was to explore community’s perception of maternity service provision in public health institutions.

Methods

A qualitative study with the underpinning philosophy of phenomenology was conducted in five subcities of Mekelle city, Ethiopia. Focus group discussions (FGDs) and in-depth interviews (IDSs) with participants who are residing in Mekelle city and who experienced maternity service as a client or as attendants were conducted to collect the necessary information. Using a semi-structured tool that has been translated into the local language, collected data were analyzed thematically using computer-assisted qualitative data analysis software ATLAS version 7. Qualitative data were transcribed through replaying the tape recorded interview from IDIs and FGDs. The text was carefully read and similar ideas were organized together. The participant's inductive meanings were extracted verbatim and described in narratives. The researcher and research assistants independently transcribed participant's comments verbatim to confirm the reliability of the findings.

Results

Participants reported that maternal health services in public health institutions were negative. Participants described experiencing poor staff attitude, lack of prescribed drugs in the institutional pharmacies, long waiting time, family proximity by professionals, poor attention to women during labor, lack of privacy and mistreatment made them develop a negative perception towards public health institutions. Despite these complaints, participants acknowledged public health facilities for affordable, accessible, qualified personnel and usually stocked with quality medications and equipment.

Conclusion

This study revealed that the community has a negative perception of the maternal health services in the public health institutions. The main reasons for their negative perception were poor staff attitude, unavailability of prescribed drugs in the institutional pharmacies, long waiting time, family proximity by professionals, poor attention to women during labor, lack of privacy and mistreatment.

"I am alive; my baby is alive": Understanding reasons for satisfaction and dissatisfaction with maternal health care services in the context of user fee removal policy in Nigeria

Background

The main policy thrust in many sub-Saharan Africa countries’ aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood.

Methods

This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011–2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis.

Results

The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers’ attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care.

Conclusion

The findings establish a high level of beneficiaries’ satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.

Examining inequalities in access to delivery by caesarean section in Nigeria

BACKGROUND

Maternal deaths are far too common in Nigeria, and this is in part due to lack of access to lifesaving emergency obstetric care, especially among women in the poorest strata in Nigeria. Data on the extent of inequality in access to such lifesaving intervention could convince policymakers in developing an appropriate intervention. This study examines inequality in access to births by caesarean section in Nigeria.

METHODS

Data for 20,468 women who gave birth in the five years preceding 2013 Nigerian Demographic and Health Survey (DHS) were used for this study. Inequality in caesarean delivery was assessed using the concentration curve and multiple logistic regression models.

RESULTS

There was a high concentration in the utilisation of caesarean section among the women in the relatively high wealth quintile. Overall, delivery by caesarean section was 2.1%, but the rate was highest among women who had higher education and belonged to the richest wealth quintile (13.6%) and lowest among women without formal education and who belonged to the poorest wealth quintile (0.4%). Belonging to the poorest wealth quintile and having no formal education were associated with lower odds of having delivery by caesarean section.

CONCLUSION

In conclusion, women in the richest households are within the WHO's recommended level of 10-15% for caesarean birth utilisation, but women in the poorest households are so far away from the recommended rate. Equity in healthcare is still a promise, its realisation will entail making care available to those in need not only those who can afford it.

Alternative or complementary attitudes toward alternative and complementary medicines

BACKGROUND

Integrative and complementary health approaches (ICHA) are often pursued by patients facing chronic illnesses. Most of the studies that investigated the factors associated with ICHA consumption have considered that the propensity to use ICHA is a stable or fixed characteristic of an individual. However, people may prefer using ICHA in some situations and not in others, depending on the characteristics of the illness to face. Moreover, the attitude toward ICHA may differ within a single individual and between individuals so that ICHA can be used either in addition to (i.e., complementary attitude) or in place of (i.e., alternative attitude). The present study aimed at examining distinct patterns of attitudes toward ICHA in people hypothetically facing chronic illnesses that differed according to severity and clinical expression.

METHODS

We conducted a web-based study including 1807 participants who were asked to imagine that they had a particular chronic illness based on clinical vignettes (mental illnesses: depression, schizophrenia; somatic illnesses: rheumatoid arthritis, multiple sclerosis). Participants were invited to rate their perceived distress and social stigma associated with each illness as well as its perceived treatability. They also rated their belief in treatment effectiveness, and their treatment preference. Four patterns of treatment choice were determined: strictly conventional, weak or strong complementary, and alternative. Bayesian methods were used for statistical analyses.

RESULTS

ICHA were selected as complementary treatment option by more than 95% of people who hypothetically faced chronic illness. The complementary attitude towards ICHA (in addition to conventional treatment) was more frequent than the alternative one (in place of conventional treatment). Factors driving this preference included employment status, severity of illness, age and perceived distress, social stigma and treatability of the illness. When the label of illnesses was included in the vignettes, patterns of treatment preference were altered.

CONCLUSIONS

This study provides evidence that "medical pluralism" (i.e., the integration of ICHA with conventional treatment) is likely the norm for people facing both mental or somatic illness. However, our result must be interpreted with caution due to the virtual nature of this study. We suggest that taking attitudes toward ICHA into account is crucial for a better understanding of patients' motivation to use ICHA.

A reassessment of global antenatal care coverage for improving maternal health using sub-Saharan Africa as a case study

BACKGROUND

Antenatal period is an opportunity for reaching pregnant women with vital interventions. In fact, antenatal care (ANC) coverage was an indicator for assessing progress towards the Millennium Development Goals. This paper applies a novel index of service coverage using ANC, which accounts for every ANC visit. An index of service coverage gap is also proposed. These indices are additively decomposable by population groups and they are sensitive to the receipt of more ANC visits below a defined threshold. These indices have also been generalised to account for the quality of services.

METHODS

Data from recent rounds of the Demographic and Health Survey (DHS) are used to reassess ANC service coverage in 35 sub-Saharan African countries. An index of ANC coverage was estimated. These countries were ranked, and their ranks are compared with those based on attaining at least four ANC visits (ANC4+).

FINDINGS

The index of ANC coverage reflected the level of service coverage in countries. Further, disparities exist in country ranking as some countries, e.g. Cameroon, Benin Republic and Nigeria are ranked better using the ANC4+ indicator but poorly using the proposed index. Also, Rwanda and Malawi are ranked better using the proposed index.

CONCLUSION

The proposed ANC index allows for the assessment of progressive realisation, rooted in the move towards universal health coverage. In fact, the index reflects progress that countries make in increasing service coverage. This is because every ANC visit counts. Beyond ANC coverage, the proposed index is applicable to assessing service coverage generally including quality education.

Analysis of socioeconomic differences in the quality of antenatal services in low and middle-income countries (LMICs)

The desired results of increasing access and availability of antenatal care (ANC) services may not be realized if the quality of care offered is not adequate. We analyzed the content/quality of antenatal care to determine whether there are socioeconomic (education and wealth) inequalities in the services provided in 59 low and middle income countries in six WHO regions–Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia. We aggregated the most recent (2005–2015) Demographic and Health Survey for each country. The quality of content was measured on eight recommended ANC services–(1) monitoring of blood pressure; (2) tetanus injection; (3) urine analysis for protein; (4) blood test; (5) information about danger signs (6); weight (7); height measurements and (8) provision of iron-folate supplement. Descriptive and Poisson regression techniques were applied to analyse the data. We found considerable wealth and educational differences prior to controlling for known covariates. Between wealth and education, however, the disparities in the latter are larger than the former. Whereas the socioeconomic differences remained at post adjusting for residence, place and number of antenatal care, parity and region, the magnitude of change was minimal. Higher number of ANC content was provided in “other” forms of private facilities; the Latin America and Caribbean region recorded the highest number of content compared to the other regions. The hypothesized socioeconomic status on content/number of ANC services was generally supported, although the associations are substantially constrained to other variables. Efforts are made to increase the number and timing of ANC services; due recognition is needed for the content offered.