The experience of men who participated in interventions to improve demand for and utilization of maternal and child health services in northern Nigeria: a qualitative comparative study

Regional trends, spatial patterns and determinants of health facility delivery among women of reproductive age in Nigeria: A national population based cross-sectional study

BACKGROUND

Globally, about 810 women die daily from pregnancy and childbirth complications, and the burden is highest in Africa. The United Nations sustainable development goal has a maternal mortality ratio (MMR) target of 70 per 100,000 live births by 2030. Nigeria, the largest country in Africa, has an MMR of 512 per 100,000 live births, thus there is need for intensified efforts to reduce maternal deaths in the country. Proper utilisation of maternal health services including health facilities for delivery is crucial to achieving this. This study assesses the regional trends, spatial patterns and determinants of health facility delivery among women of reproductive age in Nigeria.

METHODS

This is a weighted secondary analysis of the Nigerian Demographic and Health Survey (NDHS). The sample included women who had a live birth in the preceding 5 years of the NDHS 2008, 2013 and 2018. Bivariate analysis and multilevel logistic regression were carried out to assess the determinants of health facility delivery. Trends analysis was done using bar graphs and spatial analysis showed the distribution of health facility delivery by State.

RESULTS

Forty-one percent of women delivered their last child in a health facility. The proportion of women who delivered at a health facility increased from 2008 to 2018 for all regions, with exception of the South-south region. Determinants of facility-based delivery include; ethnicity, level of education, wealth index, exposure to mass media (AOR 1.34; 95% CI 1.20-1.50), number of childbirths, number of antenatal visits (AOR 4.03; 95% CI 3.51-4.62), getting a companion to go the health facility (AOR 0.84; 95% CI 0.72-0.98), community level poverty, community level of female education, community distance to health facility, and geographical region.

CONCLUSION

There is an urgent need to deploy appropriate strategies and programme to improve health facility delivery in Nigeria.

"We help people change harmful norms": Working with key opinion leaders to influence MNCH+N behaviors in Nigeria

BACKGROUND

Nigeria's Maternal, newborn, and child health and nutrition (MNCH+N) outcomes rank among the world's poorest. Engaging traditional and religious leaders shows promise in promoting related behaviors. The Breakthrough ACTION/Nigeria project worked with leaders in northern Nigeria to implement the Advocacy Core Group (ACG) model, a social and behavior change (SBC) approach aimed at influencing community norms and promoting uptake of MNCH+N behaviors. Qualitative assessment of the model contributes to evidence on SBC approaches for enhancing integrated health behaviors.

METHODOLOGY

This qualitative study was conducted in Nigeria's Bauchi and Sokoto states in May 2021. It involved 51 in-depth interviews and 24 focus group discussions. The study was grounded in the social norms exploration (SNE) technique to examine normative factors influencing behavior change within the ACG model context. Data analysis used a reflexive thematic analysis approach. Ethical approvals were received from all involved institutions and informed consent was obtained from participants.

RESULTS

The ACG model was vital in the uptake of MNCH+N behaviors. The influence of ACG members varied geographically with greater impact observed in Sokoto State. Normative barriers to improving MNCH+N outcomes included perceived religious conflicts with family planning, preference for traditional care in pregnancy, misinformation on exclusive breastfeeding (EBF), and gender-based violence resulting from women's decision-making. The study demonstrated positive progress in norm shifting, but EBF and GBV norms showed slower changes. Broader challenges within the health system, such as inadequate services, negative attitudes of healthcare providers, and workforce shortages, hindered access to care.

CONCLUSION

The ACG model increased awareness of health issues and contributed to potential normative shifts. However, slower changes were observed for EBF and GBV norms and broad health system challenges were reported. The model appears to be a promising strategy to further drive SBC for better health outcomes, especially where it is combined with supply-side interventions.

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.

Acceptance of the Advocacy Core Group approach in promoting integrated social and behaviour change for MNCH+N in Nigeria: a qualitative study

OBJECTIVE

This paper examines the acceptance of the Advocacy Core Group (ACG) programme, a social and behaviour change intervention addressing maternal, newborn, child health and nutrition (MNCH+N) in Bauchi and Sokoto states, with an additional focus on the perceived endorsement of health behaviours by social networks as a potential factor influencing acceptance.

DESIGN

This study used the qualitative social network analysis approach and used in-depth interviews to collect data from 36 participants across Bauchi and Sokoto states.

SETTING

This study was conducted in selected communities across Bauchi and Sokoto states.

PARTICIPANTS

A purposive sample of 36 participants comprised of men and women aged 15-49 years who have been exposed to the ACG programme.

RESULTS

Programme beneficiaries actively engaged in various ACG-related activities, including health messaging delivered through religious houses, social gatherings, home visits, community meetings and the media. As a result, they reported a perceived change in behaviour regarding exclusive breast feeding, antenatal care visits, family planning and malaria prevention. Our findings indicated consistent discussions on health behaviours between programme beneficiaries and their network partners (NPs), with a perceived endorsement of these behaviours by the NPs. However, a potential negative factor emerged, whereby NPs exhibited perceived disapproval of key behaviours, which poses a threat to behaviour adoption and, consequently, the success of the ACG model.

CONCLUSIONS

While findings suggest the successful implementation and acceptance of the model, it is important to address possible barriers and to further explore the socially determined acceptance of MNCH+N behaviours by NPs. Interventions such as the ACG model should mobilise the networks of programme participants, particularly those with decision-making power, to improve the uptake of health behaviours.

Psychosocial influences on pregnancy and childbirth behaviours in north-western Nigeria: a cross-sectional analysis

Antenatal care (ANC) and facility delivery are essential maternal health services, but uptake remains low in north-western Nigeria. This study aimed to assess the psychosocial influences on pregnancy and childbirth behaviours in Nigeria. Data were from a cross-sectional population-based survey of randomly sampled women with a child under 2 years conducted in Kebbi, Sokoto and Zamfara states of north-western Nigeria in September 2019. Women were asked about their maternal health behaviours during their last pregnancy. Psychosocial metrics were developed using the Ideation Model of Strategic Communication and Behaviour Change. Predicted probabilities for visiting ANC four or more times (ANC4+) and giving birth in a facility were derived using mixed-effects logistic regression models adjusted for ideational and socio-demographic variables. Among the 3039 sample women, 23.6% (95% CI: 18.0-30.3%) attended ANC4+ times and 15.5% (95% CI: 11.8-20.1%) gave birth in a facility. Among women who did not attend ANC4+ times or have a facility-based delivery during their last pregnancy, the most commonly cited reasons for non-use were lack of perceived need (42% and 67%, respectively) and spousal opposition (25% and 27%, respectively). Women who knew any ANC benefit or the recommended number of ANC visits were 3.2 and 2.1 times more likely to attend ANC4+ times, respectively. Women who held positive views about health facilities for childbirth had 1.2 and 2.6 times higher likelihood of attending ANC4+ times and having a facility delivery, respectively, while women who believed ANC was only for sickness or pregnancy complications had a 17% lower likelihood of attending ANC4+ times. Self-efficacy and supportive spousal influence were also significantly associated with both outcomes. To improve pregnancy and childbirth practices in north-western Nigeria, Social and Behavioural Change programmes could address a range of psychosocial factors across cognitive, emotional and social domains which have been found in this study to be significantly associated with pregnancy and childbirth behaviours: raising knowledge and dispelling myths, building women's confidence to access services, engaging spousal support in decision-making and improving perceived (and actual) maternal health services quality.

Factors associated with the uptake of Intermittent Preventive Treatment (IPTp-SP) for malaria in pregnancy: Further analysis of the 2018 Nigeria Demographic and Health Survey

Pregnancy-associated malaria is preventable and curable with intermittent preventive treatment with Sulfodoxine-Pyrimethamine (IPTp-SP). However, despite the effectiveness of IPTp-SP against malaria in pregnancy, the uptake among pregnant women in Nigeria remains very low. Thus, this study aimed to establish the factors associated with the uptake of at least one dose and optimal doses of IPTp-SP among pregnant women aged 15 to 49 years living in Nigeria in 2018. The study included 12,742 women aged 15 to 49 years with live births two years before or during the 2018 Nigeria Demographic Health Survey (NDHS) in the analysis. Descriptive analysis was carried out to determine the prevalence of IPTp-SP uptake. Multivariable logistic regression was used to establish the factors associated with receiving IPTp-SP during pregnancy, adjusting for possible confounding factors. Given the complex survey design, all analyses are adjusted for sampling weight, stratification, and clustering. The p-value of <0.05 was considered significant. In 2018, the prevalence of at least one dose of IPTp-SP was 63.6% (95% CI:62.0-65.1), and optimal doses of IPTp-SP were 16.8% (95% CI:15.8-17.8) during pregnancy. After the multivariable analysis, age group, region, frequency of ANC visits, belief in IPTp-SP effectiveness, and morbidity caused by malaria predicted the uptake of at least one IPTp-SP dose. Similar maternal characteristics, including household wealth index, spouse's educational level, and media exposure were significantly associated with taking optimal IPTp-SP doses. For instance, women in the wealthiest households whose husbands had secondary education predicted a four-fold increase in uptake of at least one IPTp-SP dose (aOR:4.17; 95% CI:1.11-8.85). The low prevalence and regional variations of IPTp-SP uptake in the study area imply that most pregnant women in Nigeria are at substantial risk of pregnancy-associated malaria. Therefore, stakeholders should explore context-specific strategies to improve the IPTp-SP coverage across the regions in Nigeria.

The influence of men on HPV vaccination of their spouse/partner in China

Men involvement in HPV vaccine advocacy is important in a patriarchal society. This study aimed to investigate the influence of men on HPV vaccination of adult women. An online cross-sectional survey was undertaken between June and August 2019. Participants were fathers of children enrolled in schools in Fujian Province. A total of 1953 participants responded to our survey. Just over 60% reported they would definitely or likely support their spouse/partner to receive HPV vaccine. Physician recommendation (adjusted odds ratio [aOR] = 5.68, 95%CI = 3.89–6.86) and spouse/partner communication about HPV vaccination (aOR = 5.30, 95%CI = 3.72–7.55) were significant covariates associated with higher willingness to support women’s HPV vaccination. Perceiving HPV vaccination as only for women who have had multiple sex partners and HPV vaccination as a sensitive topic were significantly associated with lower willingness to support HPV vaccination. Over two-thirds (67.3%) reported joint HPV vaccination decision-making and 2.8% reported that it was entirely the man’s decision. The role of men in HPV vaccine acceptance and hesitancy among adult women is evident in China and warrants educational interventions to target men to enhance women’s HPV vaccination uptake.

Maternal and paternal involvement in complementary feeding in Kaduna State, Nigeria: The continuum of gender roles in urban and rural settings

Household gender roles influence infant and young child feeding behaviours and may contribute to suboptimal complementary feeding practices through inequitable household decision‐making, intra‐household food allocation and limited paternal support for resources and caregiving. In Igabi local government area of Kaduna State, Nigeria, the Alive & Thrive (A&T) initiative implemented an intervention to improve complementary feeding practices through father engagement. This study describes household gender roles among A&T participants and how they influence maternal and paternal involvement in complementary feeding. We conducted 16 focus group discussions with mothers and fathers of children aged 6–23 months in urban and rural administrative wards and analysed them using qualitative thematic analysis methods. Most mothers and fathers have traditional roles with fathers as ‘providers’ and ‘supervisors’ and mothers as ‘caregivers’. Traditional normative roles of fathers limit their involvement in ‘hands‐on’ activities, which support feeding and caring for children. Less traditional normative roles, whereby some mothers contributed to the provision of resources and some fathers contributed to caregiving, were also described by some participants and were more salient in the urban wards. In the rural wards, more fathers expressed resistance to fathers playing less traditional roles. Fathers who participated in caregiving tasks reported respect from their children, strong family relationships and had healthy home environments. Our research findings point to the need for more context‐specific approaches that address prevalent gender normative roles in complementary feeding in a variety of settings.

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Some mothers and fathers still hold traditional attitudes about their roles in feeding and caring for children.

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Traditional gender normative roles of fathers limit their involvement in the ‘hands‐on’ activities that support feeding and caring for children.

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Some mothers and fathers are performing ‘non‐traditional’ gender normative roles despite social disapproval.

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The shifts from the traditional roles of mothers and fathers are more salient in urban compared with rural wards.

Scoping review of maternal and newborn health interventions and programmes in Nigeria

OBJECTIVE

To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY CRITERIA

Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included.

DATA EXTRACTION AND ANALYSIS

The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed.

RESULTS

A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively.

CONCLUSION

Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.