Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria

A review of epidemiology of lymphatic filariasis in Nigeria

Lymphatic filariasis is a neglected tropical disease that affects the lymphatic system of humans. The major etiologic agent is a nematode called Wuchereria bancrofti, but Brugia malayi and Brugia timoriare sometimes encountered as causative agents. Mosquitoes are the vectors while humans the definitive hosts respectively. The burden of the disease is heavier in Nigeria than in other endemic countries in Africa. This occurs with increasing morbidity and mortality at different locations within the country, the World Health Organization recommended treatments for lymphatic filariasis include the use of Albendazole (400mg) twice per year in co-endemic areas with loa loa, Ivermectin (200mcg/kg) in combination with Albendazole (400mg) in areas that are co-endemic with onchocerciasis, ivermectin (200mcg/kg) with diethylcarbamazine citrate (DEC) (6mg/kg) and albendazole (400mg) in areas without onchocerciasis. This paper covered a systematic review, meta-analysis, and scoping review on lymphatic filariasis in the respective geopolitical zones within the country. The literature used was obtained through online search engines including PubMed and Google Scholar with the heading "lymphatic filariasis in the name of the state", Nigeria. This review revealed an overall prevalence of 11.18% with regional spread of Northwest (1.59%), North Central and North East, (4.52%), South West (1.26%), and South-South with South East (3.81%) prevalence. The disease has been successfully eliminated in Argungu local government areas (LGAs) of Kebbi State, Plateau, and Nasarawa States respectively. Most clinical manifestations (31.12%) include hydrocele, lymphedema, elephantiasis, hernia, and dermatitis. Night blood samples are appropriate for microfilaria investigation. Sustained MDAs, the right testing methods, early treatment of infected cases, and vector control are useful for the elimination of lymphatic filariasis for morbidity management and disability prevention in the country. Regional control strategies, improved quality monitoring of surveys and intervention programs with proper records of morbidity and disability requiring intervention are important approaches for the timely elimination of the disease in Nigeria.

"I don't like to be seen by a male provider": health workers' strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria

BACKGROUND

Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria.

METHODS

We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5 y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data.

RESULTS

Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility-related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands' disapproval hindered the use of health facilities for childbirth.

CONCLUSIONS

This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility-based delivery and birth preparedness.

How applicable is geospatial analysis in maternal and neonatal health in sub-Saharan Africa? A systematic review

Background

Sub-Saharan Africa (SSA) has the world's highest maternal and neonatal morbidity and mortality and has shown the slowest progress in reducing them. In addition, there is substantial inequality in terms of maternal and neonatal morbidity and mortality in the region. Geospatial studies can help prioritize scarce resources by pinpointing priority areas for implementation. This systematic review was conducted to explore the application of geospatial analysis to maternal and neonatal morbidity and mortality in SSA.

Methods

A systematic search of PubMed, SCOPUS, EMBASE, and Web of Science databases was performed. All observational and qualitative studies that reported on maternal or neonatal health outcomes were included if they used a spatial analysis technique and were conducted in a SSA country. After removing duplicates, two reviewers independently reviewed each study's abstract and full text for inclusion. Furthermore, the quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Finally, due to the heterogeneity of studies, narrative synthesis was used to summarize the main findings, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed to report the review results. A total of 56 studies were included in the review.

Results

We found that geospatial analysis was used to identify inequalities in maternal and neonatal morbidity, mortality, and health care utilization and to identify gaps in the availability and geographic accessibility of maternal health facilities. In addition, we identified a few studies that used geospatial analysis for modelling intervention areas. We also detected challenges and shortcomings, such as unrealistic assumptions used by geospatial models and a shortage of reliable, up-to-date, small-scale georeferenced data.

Conclusions

The use of geospatial analysis for maternal and neonatal health in SSA is still limited, and more detailed spatial data are required to exploit the potential of geospatial technologies fully.

Geospatial distribution and bypassing health facilities among National Health Insurance Scheme enrollees: implications for universal health coverage in Nigeria

Background

This study was carried out to enable an assessment of geospatial distribution and access to healthcare facilities under the National Health Insurance Scheme (NHIS) of Nigeria. The findings will be useful for efficient planning and equitable distribution of healthcare resources.

Methods

Data, including the distribution of selected health facilities, were collected in Ibadan, Nigeria. The location of all facilities was recorded using Global Positioning System and was subsequently mapped using ArcGIS software to produce spider-web diagrams displaying the spatial distribution of all health facilities.

Results

The result of clustering analysis of health facilities shows that there is a statistically significant hotspot of health facility at 99% confidence located around the urban areas of Ibadan. The significant hotspot result is dominated by a feature with a high value and is surrounded by other features also with high values. Away from the urban built-up area of Ibadan, health facility clustering is not statistically significant. There was also a high level (94%) of bypassing of NHIS-accredited facilities among the enrollees.

Conclusions

Lopsided distribution of health facilities in the study area should be corrected as this may result in inequity of access to available health services.

Assessment of integration of emergency obstetric and newborn care in maternal and newborn care in healthcare facilities in Osun State, Nigeria

The integration of emergency obstetric and newborn care (EmONC) into maternal and newborn care is essential for its effectiveness to avert preventable maternal and newborn deaths in healthcare facilities. This study used a theory-oriented quantitative approach to document the reported extent of EmONC integration, and its relationship with EmONC training, guidelines availability and level of healthcare facility. A descriptive cross-sectional study was conducted among five hundred and five (505) healthcare providers and facility managers across the three levels of healthcare delivery. An adapted questionnaire from NoMad instrument was used to collect data on the integration of EmONC from the study participants. Ethical approval was obtained and informed consents taken from the participants. Both descriptive (frequency, percentage, mean and median) and inferential analyses (Kruskal Wallis and Mann Whitney tests) were done with statistical significance level of p<0.05 using STATA 14. The mean age of respondents was 38.68±8.27. The results showed that the EmONC integration median score at the three levels of healthcare delivery was high (77 (IQR = 83–71)). The EmONC integration median score were 76 (IQR = 84–70), 76 (IQR = 80–68) and 78 (IQR = 84–74) in the primary, secondary and tertiary healthcare facilities respectively. Integration of EmONC was highest (83 (IQR = 87–78)) among healthcare providers who had EmONC training and also had EmONC guidelines made available to them. There were significant differences in EmONC integration at the three levels of healthcare delivery (p = 0.046), among healthcare providers who had EmONC training and those with EmONC guidelines available in their maternity units (p = 0.001). EmONC integration was reportedly high and significantly associated with EmONC training and availability of guidelines. However, the congruence of reported and actual extent of integration of EmONC at the three levels of healthcare delivery still need validation as such would account for the implementation success and maternal-neonatal outcomes.

Levels, Trends, and Inequalities in Using Institutional Delivery Services in Low- and Middle-Income Countries: A Stratified Analysis by Facility Type

Despite improvements in the use of institutional delivery services around the world, progress has not been uniform across low- and middle-income countries. Persistent and growing inequalities in the utilization of institutional delivery services warrant the attention of policy makers for further investments and policy reviews.

Introduction:

To ensure equitable and accessible services and improved utilization of institutional delivery it is important to identify what progress has been achieved, whether there are vulnerable and disadvantaged groups that need specific attention and what are the key factors affecting the utilization of institutional delivery services. In this study, we examined levels, trends, and inequalities in the utilization of institutional delivery services in low- and middle-income countries.

Methods:

We used nationally representative cross-sectional data from Demographic and Health Surveys (DHS) conducted during 1990–2018. Bayesian linear regression analysis was performed.

Results:

Among 74 countries, the utilization of institutional delivery services ranged from 23.7% in Chad to 100% in Ukraine and Armenia (with >90% in 19 countries and <50% in 13 countries) during the latest DHS rounds. Trend analysis in 63 countries with at least 2 surveys showed that the utilization of institutional delivery services increased in 60 countries during 1990–2018, with the highest increase being in Cambodia (18.3%). During this period, the utilization of institutional delivery services increased in 90.3% of countries among the richest, 95.2% of countries in urban, and 84.1% of countries among secondary+ educated women. The utilization of institutional delivery services was higher among wealthiest, urban, and secondary+ educated women compared to their counterparts. Greater utilization of private facilities for delivery was observed in women from the highest income group and urban communities, whereas highest utilization of public facilities was observed for women from the lowest income group and rural communities.

Conclusions:

The utilization of institutional delivery services varied substantially between and within countries over time. Significant disparities in service utilization identified in this study highlight the need for tailored support for women from disadvantaged and vulnerable groups.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

BACKGROUND

In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries.

METHODS

We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors.

RESULTS

The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play.

CONCLUSIONS

Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.

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.

Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016

Background

Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa.

Methods

We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population.

Results

The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest.

Conclusions

The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

The impacts of quantity and quality of health clinics on health behaviors and outcomes in Nigeria: analysis of health clinic census data

Background

Past studies have identified that inconvenient access to health clinics is one of the important barriers to health service utilization and health outcomes. However, establishing the link between the lack of access to health clinics and the high maternal and child morbidity and mortality in Nigeria has been a challenge due to the lack of data. This paper overcomes this problem by using the country’s health clinic census data.

Methods

Using the Nigerian health clinic census, we evaluate the intercorrelation between the quantity and the quality of health clinics available across the country. We also examine the correlation between the access to health clinics and health behaviors/outcomes for residents by merging the health clinic census data with data from the demographic and health survey (DHS). The health clinic census data makes it possible to capture the overall geographical allocation of health services across the country as well as their comprehensive relationship with health outcomes.

Results

We find a strong positive correlation between the quality of a health clinic and the quantity and quality of neighboring clinics. The high quality clinics are concentrated in areas where the density of clinics is high, and where more of the clinics around them are also of high quality. We also find that an increase in access to health clinics of high quality that are in close proximity is significantly and positively correlated with an improvement in health behaviors as well as health outcomes. Women who are more disadvantaged benefit more from the access to high quality clinics than others.

Conclusions

Health clinics of good quality are unevenly distributed geographically in Nigeria. The quality of health clinics should be of a level that can support the promotion of recommended health behaviors and achieve improved health outcomes throughout the country. Further studies are necessary to evaluate the optimal distribution of clinics of good quality, given that residents in less populated areas gain a higher marginal benefit from improved access to health service, despite the higher costs of supplying the service in those areas.