A qualitative study of community elders' perceptions about the underutilization of formal maternal care and maternal death in rural Nigeria

Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review

BACKGROUND

The preservation and promotion of maternal health (MH) emerge as vital global health objectives. Despite the considerable emphasis on MH, there are still serious challenges to equitable access to MH services in many countries. This review aimed to determine key barriers to the provision and utilization of MH services in low- and lower-middle-income countries (LLMICs).

METHODS

In this scoping review, we comprehensively searched four online databases from January 2000 to September 2022. In this study, the approach proposed by Arksey and O'Malley was used to perform the review. Consequently, 117 studies were selected for final analysis. To determine eligibility, three criteria of scoping reviews (population, concept, and context) were assessed alongside the fulfillment of the STROBE and CASP checklist criteria. To synthesize and analyze the extracted data we used the qualitative content analysis method.

RESULTS

The main challenges in the utilization of MH services in LLMICs are explained under four main themes including, knowledge barriers, barriers related to beliefs, attitudes and preferences, access barriers, and barriers related to family structure and power. Furthermore, the main barriers to the provision of MH services in these countries have been categorized into three main themes including, resource, equipment, and capital constraints, human resource barriers, and process defects in the provision of services.

CONCLUSIONS

The evidence from this study suggests that many of the barriers to the provision and utilization of MH services in LLMICs are interrelated. Therefore, in the first step, it is necessary to prioritize these factors by determining their relative importance according to the specific conditions of each country. Consequently, comprehensive policies should be developed using system modeling approaches.

Determinants of maternal mortality in south-western Nigeria: Midwives' perceptions

BACKGROUND

Maternal mortality remains one of Nigeria's most significant public health challenges. In order to address this issue sustainably, it is necessary to consider the perceptions of all stakeholders involved, including midwives.

OBJECTIVES

To examine the determinants of maternal mortality in south-western Nigeria from the midwife's perspective.

DESIGN

A cross-sectional study was employed using mixed methods with a semi-structured questionnaire and an in-depth interview guide.

PARTICIPANTS

Quantitative data were obtained from 215 midwives using a convenience sampling technique. Qualitative data were obtained from 25 midwives from five government health centres, selected using a stratified sampling technique.

METHODS

Quantitative data were analysed using SPSS Version 20 using descriptive and inferential statistics with 95 % confidence intervals, while qualitative data were analysed using thematic analyses.

FINDINGS

The mean age and work experience of the participants were 35.2 ± 9.3 years and 8.4 ± 7.0 years, respectively. The midwives perceived that the main determinants of maternal mortality were postpartum haemorrhage (86.5 %), hypertensive disorder in pregnancy (80.9 %), mismanagement at mission homes/traditional birth attendant centres (MH/TBAs) (79.1 %) and sepsis (70.1 %). Some of the priority target areas to improve the well-being of pregnant women as identified by the midwives, were increased awareness of pregnancy danger signs (97 %), destigmatising caesarean section (CS) (96 %), regulation of MH/TBAs (92 %), and increased accessibility of hospitals (84 %). Findings from the qualitative data also affirmed that regulating MH/TBAs, destigmatising CS and subsidising healthcare expenses were prerequisites to curbing maternal mortality. Inferential analysis revealed that determinants such as unsafe abortion (p < 0.001), ectopic pregnancy (p = 0.001), domestic violence (p = 0.023), malaria (p = 0.029), short interbirth interval (p = 0.03), and patients' negative perceptions of CS delivery (p = 0.036) were more commonly perceived to be associated with maternal mortality by younger midwives (age 17-34 years) compared with older midwives.

KEY CONCLUSION

The results indicate that resolving the maternal mortality crisis sustainably in Nigeria will require increased accessibility to basic health care and health promotion campaigns to counteract unhelpful sociocultural norms.

IMPLICATIONS FOR PRACTICE

Future interventions must be tailored to address both traditional and emerging causes of maternal mortality in southwestern Nigeria.

Optimizing the utilization of maternal and reproductive healthcare services among women in low-resourced Nigerian settings

INTRODUCTION

Quality care delivery is an essential lifesaving interventions for maternal healthcare and reduction in mortality from preventable reproductive conditions. In African countries like Nigeria, numerous perceptions and militating factors present unique challenges in optimizing the utilization of maternal and reproductive healthcare services. As women continuously evolve away from the utilization of healthcare services, achieving universal health coverage for all emerges as a matter of concern.

METHOD

A phenomenological and descriptive research design was used. The study participants comprised a total of 38 women selected from primary and tertiary healthcare institutions. They were purposively selected from four healthcare institutions in Nsukka, Enugu State, Nigeria.

RESULT

Findings revealed that most rural women at the prenatal stage, utilize maternal healthcare services, but at the postnatal stage, they reject reproductive healthcare services owing to certain perceptions. Concerns about sub-optimal utilization of maternal and reproductive healthcare services were found under enabling, predisposing and need factors. Evidence-based interventions included instituting health insurance policies, improving the healthcare sector, personnel, collaboration among stakeholders, and grass-roots community education. Participants showed little knowledge of social workers' engagement in healthcare institutions.

CONCLUSION

Functional network of care between private and public healthcare system is the key to optimizing maternal and reproductive healthcare utilization. The study recommends stakeholder and community engagement in achieving functional networks of care, strengthening relational linkages between frontline health workers and equip rural women with better knowledge. All these are geared toward achieving optimal utilization of maternal and reproductive healthcare services among women in low-resourced Nigerian settings.

Seeking maternal health care in rural Nigeria: through the lens of negofeminism

BACKGROUND

Feminist scholarship is acutely aware that health is not dependent on behavioural choices alone but on interlocking social determinants that affect people's capacity to lead healthy lives. Women are situated within social structures that impact their health. but there is limited engagement with interpretive tools such as feminist theories that centre the realities of African women, particularly in the context of maternal health. It is imperative that women's control over their reproductive health and autonomy in seeking care, particularly skilled maternal healthcare are understood within this context. This study seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Feminist scholarship acknowledges that women are situated within social structures that impact their health. Therefore, this paper seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism.

METHOD

This is a cross-sectional qualitative study of a total of 64 participants: 39 women and 25 men in Ewato and Okpekpe communities, two Local Government Areas of Edo State in southern Nigeria. The study presents findings from eight sex-and-age desegregated focus group discussions. This study reports on emergent data related to women's decision-making in accessing skilled maternal care. Data were transcribed and translated to English. Using the NVivo 1.6 software, data were coded and analyzed using a conventional approach to content analysis.

RESULTS

Findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism's concepts of alliance, community and connectedness were highlighted through men's constructive involvement in maternal health. Furthermore, women were shown to maneuver patriarchal norms to gain control of their healthcare decisions.

CONCLUSION

This study offers a different narrative from the dominant view of non-Western women, specifically African women, as oppressed passive victims who are ineffectual in taking charge of their health. From the perspective of negofeminism, women navigate patriarchal environments to yield the best possible maternal health outcomes. The current study can be useful in informing policy and programming that acknowledges women's social embeddedness.

Community perceptions and experiences on the events leading to facility maternal death; a verbal autopsy qualitative study

BACKGROUND

Tanzania Maternal Death Surveillance and Response (MDSR) system introduced in 2015 emphasizes review of facility maternal deaths with little community involvement. Involving the community in deaths enquiry can help to make better strategies to prevent future deaths. We aimed to explore family members (caregivers) perceptions and experiences on the events leading to facility maternal deaths to inform future community involvement in MDSR.

METHODS

Narrative interviews were conducted with 20 caregivers who cared for women who died in childbirth to investigate into delays and health care seeking experience. The unstructured questions on perceptions and experiences of events leading to death were administered together with standard verbal autopsy questionnaire. Two regions, Lindi and Mtwara of Southern Tanzania were selected for the study in 2018. Narrative thematic analysis was used for data analysis.

RESULTS

Three main themes evolved: 'Prepared for birth but not ready for complications', 'Disconnect between caregivers and providers' and 'The bitter impact of maternal deaths. Caregivers made efforts to prepare for birth but their preparation were severely inadequate when complications that necessitated referral occurred. Decision to seek care was made jointly between the pregnant woman, husband and other family members. Caregivers tried with little success in communicating with heathcare providers regarding their admitted patients. They also experienced emotions of grief such as denial, anger, depression, bargaining and acceptance once maternal deaths occurred. Caregivers (mostly old women) were left with the burden of caring for the newborns and other children left by the deceased mother.

CONCLUSION

Caregivers' perceptions and experiences of maternal deaths events provide valuable information for community interventions on birth preparedness, decision making, communication and providers' accountability. Maternal deaths bring far reaching mental, social and economic consequences to the family and society.

Cultural beliefs and practices on perinatal death: a qualitative study among the Lango community in Northern Uganda

BACKGROUND

Perinatal death has profound psychosocial effects on women and their families. Sociocultural contexts influence the burden, rituals and bereaved's support. Little is known about cultural beliefs and practices related to perinatal death. This study explored the cultural perspectives of the Lango community on perinatal death.

METHODS

This study utilised a focused ethnographic design anchored on a symbolic interactionist framework to understand the meanings attached to beliefs and practices on stillbirth or neonatal death among the Lango community in Lira District, Northern Uganda. Participants were sampled purposively for FGD while key informants were identified through snowballing technique. Data were audio recorded in Lango, transcribed, and later translated, a codebook was developed and data entered into Atlas. ti version 8.4.26 and then coded. It was analysed both deductively and inductively into themes.

RESULTS

Stillbirth and early neonatal death both attract similar rituals as would an older child. Burial is not rushed and is attended by family members and close friends. Stillbirths and children that die before naming are buried without names. Bereaved families are comforted and encouraged about future pregnancies. Currently, Lango associates the deaths to biomedical explanations such as teenage pregnancies, inadequate pregnancy care, health system challenges and poor health-seeking behaviour, unlike previously when they were attributed to consequences of unacceptable social behaviours, superstitious beliefs and witchcraft. Antenatal care and health facility childbirths are currently preferred over traditional practices for good pregnancy outcomes.

CONCLUSION

Stillbirth or early neonatal death is viewed as the death of a child, different from other settings. Thus, rituals are performed to honour, create memory, and maintain the connection with deceased babies. Bereaved parents are supported. Health care workers need to provide culturally sensitive support to parents after perinatal loss. The prevailing beliefs of perinatal death cause in terms of biomedical explanations consistent with known determinants and preference for health facility care for prevention creates an opportunity for improving perinatal health.

'We delivered at home out of fear': Maternity Care in Rural Nigeria During the COVID-19 Pandemic

Background and Objective

The COVID-19 pandemic response overwhelmed health systems, disrupting other services, including maternal health services. The disruptive effects on the utilization of maternal health services in low-resource settings, including Nigeria have not been well documented. We assessed maternal health service utilization, predictors, and childbirth experiences amidst COVID-19 restrictions in a rural community of Kumbotso, Kano State, in northern Nigeria.

Methods

Using an explanatory mixed methods design, 389 mothers were surveyed in January 2022 using validated interviewer-administered questionnaires, followed by in-depth interviews with a sub-sample (n=20). Data were analyzed using logistic regression models and the framework approach.

Results

Less than one-half (n=165, 42.4%) of women utilized maternal health services during the period of COVID-19 restrictions compared with nearly two-thirds (n=237, 65.8%) prior to the period (p<0.05). Non-utilization was mainly due to fear of contracting COVID-19 (n=122, 54.5%), clinic overcrowding (n=43, 19.2%), transportation challenges (n=34, 15.2%), and harassment by security personnel (n=24, 10.7%). The utilization of maternal health services was associated with participant's post-secondary education (aOR=2.06, 95% CI:1.14- 11.40) (p=0.02), and employment type (civil service, aOR=4.60, 95% CI: 1.17-19.74) (p<0.001), business aOR=1.94, 95% CI:1.19- 4.12) (p=0.032) and trading aOR=1.62, 95% CI:1.19-2.94) (p=0.04)). Women with higher household monthly income (≥ N30,000, equivalent to 60 US Dollars) (aOR=1.53, 95% CI:1.13-2.65) (p=0.037), who adhered to COVID-19 preventive measures and utilized maternal health services before the COVID-19 pandemic were more likely to utilize those services during the COVID-19 restrictions. In contrast, mothers of higher parity (≥5 births) were less likely to use maternal health services during the lockdown (aOR=0.30, 95% CI:0.10-0.86) (p=0.03). Utilization of maternal services was also associated with partner education and employment type.

Conclusion and Global Health Implications

The utilization of maternal health services declined during the COVID-19 restrictions. Utilization was hindered by fear of contracting COVID-19, transport challenges, and harassment by security personnel. Maternal and partner characteristics, adherence to COVID-19 preventive measures, and pre-COVID maternity service utilization influenced attendance. There is a need to build resilient health systems and contingent alternative service delivery models for future pandemics.

Perception of men's need for preconception care-A qualitative exploration among health care providers and community members

Background

Several studies have shown that suboptimal health in men can result in poor reproductive health outcomes. The factors associated include lifestyle exposures and poor health-seeking behavior. The poor reproductive health outcomes can be mitigated through preconception care (PCC). PCC services for men are however rare. This qualitative study explored views about men's need for PCC in Nigeria.

Methods

This exploratory qualitative study was done in Ibadan North Local Government Area, Oyo State, Nigeria. Focus group discussions were held with 12 religious leaders, 22 men and 23 women of reproductive age at the community level. There were key informant interviews with two community leaders and 26 health workers including specialist physicians and nurses at the primary, secondary, and tertiary health care levels. Transcribed data were analyzed thematically using inductive coding on MAXQDA.

Results

The reasons participants proffered for men's health requiring attention included men's genetic contribution to pregnancy, treatment of low sperm count, and preventing transmission of infection to their partners. Participants stated however that men are often reluctant about accessing health services until complications arise. Opinions differed on men's need for PCC: while some believed that men need PCC, others expressed contrary views stating that men do not require PCC as the service is more appropriate for women.

Conclusion

Successful deployment and uptake of PCC services require the availability of the services and improved awareness about the need to optimize men's health along with that of their partners.

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.

Leveraging Innovative Financing Strategy to Increase Coverage and Resources Among Informal Sector for Social Health Insurance Within the Nigerian Context of Devolution: Evidence From Adoption Model Implementation

Background

Enrollment in sub-national social health insurance schemes (SSHIS) can be challenging in developing countries like Nigeria, particularly among people in the informal sector. This could be due to a lack of knowledge on its mode of operation and benefits, distrust in government, inimical religious and traditional beliefs, as well as constraining economic factors. A complementary and innovative financing strategy such as the philanthropist adoption model (ADM) could be beneficial in improving SSHIS coverage and financial resources among persons in the informal sector. The study provides new evidence on how ADM influenced health insurance coverage and resources within SSHIS among informal settings in Nigeria. It also highlights contextual factors influencing the implementation of ADM.

Methods

This study employed a mixed-methods case-study approach undertaken in Anambra State, Southeast Nigeria. Data were collected through in-depth interviews (n = 14), document review (n = 12), and quantitative (enrollment data) methods. The respondents were purposively selected based on their involvement with the implementation of the SSHIS. Data analysis for qualitative data was done using the manual thematic framework approach while descriptive analysis was performed for the quantitative data.

Results

The implementation of ADM was a valuable and effective strategy for improving knowledge, coverage, and resource mobilization (annual premium pool) within the SSHIS in the informal sector. The main enablers of the implementation of ADM include strong political will and commitment, wider stakeholders' consultation and collaboration, numerous public-spirited philanthropists, and legal institutionalization of health insurance. Other enablers include organizational factors like good teamwork among Anambra State Health Insurance Agency (ASHIA) staff, enabling work environment (incentives, supervision, office space), and experienced marketers in the agency. However, ADM had several barriers that affected its implementation—acceptability issues due to distrust for government and the health system, health systems barriers including substandard health facilities and equipment, and inimical cultural and religious beliefs about health insurance.

Conclusion

The study demonstrates a case for the implementation of innovative ADM as a strategy for enhancing SSHIS financial sustainability and coverage of persons in the informal sector. Hence, the strategy should be adopted in settings where philanthropy abounds for increasing access to quality healthcare delivery to poor beneficiaries toward achieving universal health coverage in developing countries.

Effect of a multifaceted intervention on the utilisation of primary health for maternal and child health care in rural Nigeria: a quasi-experimental study

OBJECTIVE

The objective of this study was to determine the effectiveness of a set of multifaceted interventions designed to increase the access of rural women to antenatal, intrapartum, postpartum and childhood immunisation services offered in primary healthcare facilities.

DESIGN

The study was a separate sample pretest-post-test quasi-experimental research.

SETTING

The research was conducted in 20 communities and primary health centres in Esan South East and Etsako East Local Government Areas in Edo State in southern Nigeria PARTICIPANTS: Randomly selected sample of ever married women aged 15-45 years.

INTERVENTIONS

Seven community-led interventions implemented over 27 months, consisting of a community health fund, engagement of transport owners on emergency transport of pregnant women to primary health centres with the use of rapid short message service (SMS), drug revolving fund, community education, advocacy, retraining of health workers and provision of basic equipment.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measures included the number of women who used the primary health centres for skilled pregnancy care and immunisation of children aged 0-23 months.

RESULTS

After adjusting for clustering and confounding variables, the odds of using the project primary healthcare centres for the four outcomes were significantly higher at endline compared with baseline: antenatal care (OR 3.87, CI 2.84 to 5.26 p<0.001), delivery care (OR 3.88, CI 2.86 to 5.26), postnatal care (OR 3.66, CI 2.58 to 5.18) and childhood immunisation (OR 2.87, CI 1.90 to 4.33). However, a few women still reported that the cost of services and gender-related issues were reasons for non-use after the intervention.

CONCLUSION

We conclude that community-led interventions that address the specific concerns of women related to the bottlenecks they experience in accessing care in primary health centres are effective in increasing demand for skilled pregnancy and childcare in rural Nigeria.

Assessment of service readiness for maternity care in primary health centres in rural Nigeria: implications for service improvement

Introduction

several scientific reports from studies across Nigeria revealed a higher incidence of maternal mortality in rural parts of the country as compared to the urban areas. Part of the reasons is the paucity of health care infrastructure and personnel. This study was designed as part of an intervention program with the goal to improve the access of pregnant women to skilled pregnancy care in rural Nigeria. The specific objective of the study was to determine the nature and readiness of Primary Health Centres (PHCs) in two Local Government Areas (LGAs) in rural parts of Edo State, Southern Nigeria to deliver effective maternal and child health services.

Methods

the study was conducted in 12 randomly selected PHCs in the two LGAs. Data were obtained with a semi-structured questionnaire administered on health workers and through direct observation and verification of the facilities in the PHCs. The results obtained were compared with the national standards established for PHCs in Nigeria by the National Primary Health Care Development Agency (NPHCDA). Descriptive statistics were used to analyze the data.

Results

the results showed severe deficits in buildings and premises, rooms, medical equipment, essential drugs, and personnel. Only 40% of items recommended by the NPHCDA were available for buildings; 41% of the PHCs had facilities available in the labour ward; while less than 30% had the recommended facilities in the antenatal care rooms. Only one PHC had a laboratory space, with only one item (a dipstick for urine analysis) identified in the laboratory. None of the PHCs had ambulances, mobile phones, internet or computers. There was no nurse/midwife in 4 PHCs; only one nurse/midwife each were available in 8 PHCs; while there was no Environmental/Medical Records Officer in any PHC. About 26% of the essential drugs were not available in the PHCs.

Conclusion

we conclude that PHCs in Edo State, Nigeria have severe deficits in infrastructural facilities, equipment, essential drugs and personnel for the delivery of maternal and child health care. Efforts to improve these facilities will help increase the quality of delivery of maternal and child health, and therefore reduce maternal and child mortality in the country.

"It's like being involved in a car crash": teen pregnancy narratives of adolescents and young adults in Jos, Nigeria

BACKGROUND

Adolescent pregnancy has serious public health implications, with far-reaching outcomes extending past the mother and child and affecting society. The purpose of this study was to explore the lived experience of adolescent pregnancy in Jos, Nigeria.

METHODS

We conducted in-depth interviews with 17 adolescents and young women ages 16-24 y in Jos, Nigeria who had experienced at least one teenage pregnancy. Participants were purposively recruited; each provided written informed consent before interviewing. We identified codes and themes using an inductive analytic approach.

RESULTS

Among the 17 participants, 14 had never been married and 10 had completed senior secondary school. Participants commonly associated adolescent pregnancy with inappropriate behaviour, immaturity and premarital childbearing. The main risk factors for adolescent pregnancy were lack of sexual and reproductive health education and parental communication. Pregnancy evoked feelings of fear, shame, anxiety and depression. Most pregnancies resulted in live births, while some participants had stillbirths or induced abortion. Some participants successfully completed their education post-pregnancy.

CONCLUSIONS

Adolescents in this study lacked adequate sexual and reproductive health education that could empower them to make informed decisions and take action regarding their sexual and reproductive health. Multifaceted actions to address reproductive health education gaps can contribute to reducing adolescent pregnancy in Nigeria.

Community's experience and perceptions of maternal health services across the continuum of care in Ethiopia: A qualitative study

BACKGROUND

Continuum of care is an effective strategy to ensure that every woman receives a series of maternal health services continuously from early pregnancy to postpartum stages. The community perceptions regarding the use of maternal services across the continuum of care are essential for utilization of care in low-income settings but information in that regard is scanty. This study explored the community perceptions on the continuum of care for maternal health services in Ethiopia.

METHODS

This study employed a phenomenological qualitative research approach. Four focus group discussions involving 26 participants and eight in-depth interviews were conducted with women who recently delivered, community health workers, and community leaders that were purposively selected for the study in West Gojjam zone, Amhara region. All the interviews and discussions were audio-taped; the records were transcribed verbatim. Data were coded and analyzed thematically using ATLAS.ti software.

RESULTS

We identified three primary themes: practice of maternal health services; factors influencing the decision to use maternal health services; and reasons for discontinuation across the continuum of maternal health services. The study showed that women faced multiple challenges to continuously uptake maternal health services. Late antenatal care booking was the main reasons for discontinuation of maternal health services across the continuum at the antepartum stage. Women's negative experiences during care including poor quality of care, incompetent and unfriendly health providers, disrespectful care, high opportunity costs, difficulties in getting transportation, and timely referrals at healthcare facilities, particularly at health centers affect utilization of maternal health services across the continuum of care. In addition to the reverberation effect of the intrapartum care factors, the major reasons mentioned for discontinuation at the postpartum stage were lack of awareness about postnatal care and service delivery modality where women are not scheduled for postpartum consultations.

CONCLUSION

This study showed that rural mothers still face multiple challenges to utilize maternal health services as recommended by the national guidelines. Negative experiences women encountered in health facilities, community perceptions about postnatal care services as well as challenges related to service access and opportunity costs remained fundamental to be reasons for discontinuation across the continuum pathways.

Influence of Conditional Cash Transfers on the Uptake of Maternal and Child Health Services in Nigeria: Insights From a Mixed-Methods Study

Background: Increasing access to maternal and child health (MCH) services is crucial to achieving universal health coverage (UHC) among pregnant women and children under-five (CU5). The Nigerian government between 2012 and 2015 implemented an innovative MCH programme to reduce maternal and CU5 mortality by reducing financial barriers of access to essential health services. The study explores how the implementation of a financial incentive through conditional cash transfer (CCT) influenced the uptake of MCH services in the programme. Methods: The study used a descriptive exploratory approach in Anambra state, southeast Nigeria. Data was collected through qualitative [in-depth interviews (IDIs), focus group discussions (FGDs)] and quantitative (service utilization data pre- and post-programme) methods. Twenty-six IDIs were conducted with respondents who were purposively selected to include frontline health workers (n = 13), National and State policymakers and programme managers (n = 13). A total of sixteen FGDs were conducted with service users and their family members, village health workers, and ward development committee members from four rural communities. We drew majorly upon Skinner's reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH services. Manual content analysis was used in data analysis to pull together core themes running through the entire data set. Results: The CCTs contributed to increasing facility attendance and utilization of MCH services by reducing the financial barrier to accessing healthcare among pregnant women. However, there were unintended consequences of CCT which included a reduction in birth spacing intervals, and a reduction of trust in the health system when the CCT was suddenly withdrawn by the government. Conclusion: CCT improved the utilization of MCH, but the sudden withdrawal of the CCT led to the opposite effect because people were discouraged due to lack of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.

Barriers to healthcare access and healthcare seeking for childhood illnesses among childbearing women in sub-Saharan Africa: A multilevel modelling of Demographic and Health Surveys

Introduction

The success of current policies and interventions on providing effective access to treatment for childhood illnesses hinges on families’ decisions relating to healthcare access. In sub-Saharan Africa (SSA), there is an uneven distribution of child healthcare services. We investigated the role played by barriers to healthcare accessibility in healthcare seeking for childhood illnesses among childbearing women in SSA.

Materials and methods

Data on 223,184 children under five were extracted from Demographic and Health Surveys of 29 sub-Saharan African countries, conducted between 2010 and 2018. The outcome variable for the study was healthcare seeking for childhood illnesses. The data were analyzed using Stata version 14.2 for windows. Chi-square test of independence and a two-level multivariable multilevel modelling were carried out to generate the results. Statistical significance was pegged at p<0.05. We relied on ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) statement in writing the manuscript.

Results

Eighty-five percent (85.5%) of women in SSA sought healthcare for childhood illnesses, with the highest and lowest prevalence in Gabon (75.0%) and Zambia (92.6%) respectively. In terms of the barriers to healthcare access, we found that women who perceived getting money for medical care for self as a big problem [AOR = 0.81 CI = 0.78–0.83] and considered going for medical care alone as a big problem [AOR = 0.94, CI = 0.91–0.97] had lower odds of seeking healthcare for their children, compared to those who considered these as not a big problem. Other factors that predicted healthcare seeking for childhood illnesses were size of the child at birth, birth order, age, level of community literacy, community socio-economic status, place of residence, household head, and decision-maker for healthcare.

Conclusion

The study revealed a relationship between barriers to healthcare access and healthcare seeking for childhood illnesses in sub-Saharan Africa. Other individual and community level factors also predicted healthcare seeking for childhood illnesses in sub-Saharan Africa. This suggests that interventions aimed at improving child healthcare in sub-Saharan Africa need to focus on these factors.

Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria

Background

The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country’s very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women’s access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women’s use of skilled pregnancy care in rural Edo State, Nigeria.

Methods

This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches.

Results

Stakeholders identified barriers to pregnant women’s use of skilled pregnancy care and they include; financial constraints, women’s lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women’s use of skilled pregnancy care.

Conclusions

This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women’s health behaviour. Therefore, initiatives seeking to improve pregnant women’s use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.