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Background: In Nigeria, hypertensive disorders have become the leading cause of facility-based maternal mortality. Many factors influence pregnant women’s health-seeking behaviors and perceptions around the importance of antenatal care. This qualitative study describes the care-seeking pathways of Nigerian women who suffer from pre-eclampsia and eclampsia. It identifies the influences-barriers and enablers-that affect their decision making, and proposes solutions articulated by women themselves to overcome the obstacles they face. Informing this study is the health belief model, a cognitive value-expectancy theory that provides a framework for exploring perceptions and understanding women’s narratives around pre-eclampsia and eclampsia-related care seeking. Methods: This study adopted a qualitative design that enables fully capturing the narratives of women who experienced pre-eclampsia and eclampsia during their pregnancy. In-depth interviews were conducted with 42 women aged 17-48 years over five months in 2015 from Bauchi, Cross River, Ebonyi, Katsina, Kogi, Ondo and Sokoto states to ensure representation from each geo-political zone in Nigeria. These qualitative data were analyzed through coding and memo-writing, using NVivo 11 software. Results: We found that many of the beliefs, attitudes, knowledge and behaviors of women are consistent across the country, with some variation between the north and south. In Nigeria, women’s perceived susceptibility and threat of health complications during pregnancy and childbirth, including pre-eclampsia and eclampsia, influence care-seeking behaviors. Moderating influences include acquisition of knowledge of causes and signs of pre-eclampsia, the quality of patient-provider antenatal care interactions, and supportive discussions and care seeking-enabling decisions with families and communities. These cues to action mitigate perceived mobility, financial, mistrust, and contextual barriers to seeking timely care and promote the benefits of maternal and newborn survival and greater confidence in and access to the health system. Conclusions: The health belief model reveals intersectional effects of childbearing norms, socio-cultural beliefs and trust in the health system and elucidates opportunities to intervene and improve access to quality and respectful care throughout a woman’s pregnancy and childbirth. Across Nigerian settings, it is critical to enhance context-adapted community awareness programs and interventions to promote birth preparedness and social support.
This study adopted a qualitative design that fully captures the narratives of women who experienced pre-eclampsia and eclampsia during their pregnancy. Data were collected over a five-month period from April to August 2015 in seven states across Nigeria: Bauchi, Cross River, Ebonyi, Katsina, Kogi, Ondo and Sokoto. Selected states include representation from each geo-political zone, covering the cultural diversity, varied socioeconomic development and differential access to health care services. Forty-four individual in-depth interviews (IDIs) were conducted with women who experienced pre-eclampsia, purposively selected and recruited in the community through health facility referrals by community health extension workers. Participants were identified as survivors of pre-eclampsia by health care providers who managed – provided some level of care and referral – during women’s labor and deliveries. While survivors likely experienced danger signs, they all received care either during ANC, childbirth, and/or in the early postpartum period. Eligibility criteria was not restricted to women who delivered in facilities nor differentiated on progression to eclampsia prior to care-seeking. The data collection team used a contact tracing approach and engaged local guides to recruit women and interview them in the community. Data collectors experienced in qualitative methods and reproductive health were trained on study topics, interview guides, and research ethics. Data collectors had no prior established relationship with study participants. Instruments were pre-tested during the training. Women were asked open-ended questions related to their pregnancy, delivery, and postnatal experiences using a structured guide (Additional file 1) that included probes on quality of ANC, knowledge of pre-eclampsia and eclampsia, and factors that affect care seeking at individual, household, community and health systems levels. Socio-demographic information was collected to contextualize our findings. After obtaining written informed consent from participants, data collectors conducted interviews in local languages including Hausa (Bauchi, Katsina, Kogi, and Sokoto), Yoruba (Ondo), Igbo (Ebonyi), and Ibibio (Cross River). Care was taken to interview women in private settings. Two people attended each interview; one conducted the interview and the other took field notes. Interviews were audio-recorded, transcribed verbatim and translated into English. With a grounded theory orientation, after an initial reading of the transcripts, a code structure was inductively developed, discussed, and applied to the data using the NVivo 11 qualitative software by two researchers. Memos written while coding the data allowed researchers to describe similarities and differences in women’s perspectives between states, by age of marriage and parity, as well as emergently relevant characteristics. Through a deliberative process, researchers further grouped codes into themes and analyzed the local findings in dialogue with the health belief model. Ethical approval for this study was granted by the Population Council’s institutional review board (Protocol #693), the National Health Research Ethics Committee of Nigeria, and research ethics committees from each study state.
