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. A qualitative research design involving key informants at district levels was used. This study forms part of a larger initiative in Edo State by the Women’s Health Action Research Centre and the University of Ottawa, funded under the Innovating for Maternal and Child Health Africa initiative (a partnership of Global Affairs Canada, Canada’s International Development Research Centre and Canadian Institutes of Health Research). As part of the formative phase of the larger study, this study was designed to inform the development of interventions for improving access to, and the use of primary health care services for maternal health in rural Nigeria. This study was conducted in Esan South East (ESE) and Etsako East (ETE), both of which are local government areas (LGA) of Edo state, one of Nigeria’s thirty-six States. Edo state was chosen because it is one of the lowest performing state in terms of developing and maintaining its PHC system. ETE is in the northern part of Edo State, while ESE is in the southern part. Both LGAs are located in mainly rural parts of the State with each having 10 political wards. ESE comprises of 16,500 residents per ward, while ETE has 14,500 per ward. The principal source of pregnancy care in the two LGAs is primary healthcare. There are 25 PHC centres in ESE and 28 in ETE. Esan South East has one general hospital in the local government’s headquarters (Ubiaja) and Etsako East has two general hospitals; one in the local government’s headquarters (Agenebode) and another in nearby Fugar City. They are used in addition to existing PHCs for referral for maternal health services. The study participants consisted of 13 stakeholders from a range of institutions in ESE and ETE LGAs in Edo State, and at the Edo State government level. They included: a senior official within the State Ministry of Health, a senior official within the State Primary Healthcare Development Agency (SPHCDA), Senior officials responsible for PHCs at the LGAs, Senior local government officials, and clinical managers. A purposeful criterion sampling technique was used to select key informants [24]. In this sampling technique, participants are chosen because they meet or exceed a specific criterion (or criteria) related to a phenomenon of interest and therefore possess the knowledge and experience to provided information that is both detailed and generalised [24]. The participants were purposefully recruited by the lead investigators (FO, WI, LN) to represent different backgrounds and professions. The lead investigators contacted each participant by email (or phone) with information about the study and sought their voluntary participation and informed consent. The criteria for participation was that key informants occupy a key position and had experience within the PHC system thus enabling them offer rich insights for addressing the study objectives. Interviews were conducted in English by trained investigators. The lead investigators (FO, LN) and members of the technical team, who are experts in qualitative research, provided a three-day training session for the investigators. Aspects of the training included the goals of the research, the art of qualitative data collection, specifically the use of KII guides in qualitative research, the role of the data collectors, research ethics, and data collection using electronic devices such as a voice recorder. Written informed consent was sought and obtained from each study participant prior to starting the interviews. The KII guide was developed by the lead investigators and reviewed for quality assurance. On the last day of training, the trained investigators moderated the pilot of the KII guide in a community with similar characteristics to the study locations. Data collection using a KII guide took place from July 16 to August 30, 2017. Trained investigators audio recorded the interviews and took reflective field notes to supplement the transcripts. Interviews lasted for 45 mins on average and ended when no further issues arose. The KII guide developed for this study (see supplementary file) consisted of open-ended questions and follow-up probes on stakeholders’ perceptions of pregnant women’s use of skilled pregnancy healthcare in rural ESE and ETE communities. Questions explored opinions on comprehensive factors that influence pregnant women’s use of skilled healthcare services. A sample of issues discussed with participants include: The ethical clearance approval needed for the larger project was obtained from the National Health Research Ethics Committee (NHREC) on April 18, 2017 (reference number NHREC/01/01/2007–18/04/2017). All personal identifiers were removed to ensure confidentiality. Participants provided written informed consent prior to participating in this study. The in-depth interviews were audio-taped and transcribed verbatim in the original language which was English. The primary author (OU) and corresponding author (SY) analysed the data and the co-authors validated the data. To ensure accuracy, transcripts were compared with the audio-recordings and field notes. Thematic coding was applied using an iterative process of inductive and deductive approaches. In inductive approaches, themes emerging from the data were fitted into preconceived categories. For this process, Braun and Clark recommend six steps for analysing data; become familiar with the data, generate initial codes, search or themes, review themes, define themes and produce a report [25]. Deductive approaches were drawn from existing literature or theories to build on already studied concepts. Themes were generated in the following steps: Line-by-line reading generated words or phrases with similar meanings that were linked to the study’s objective and existing literature on pregnancy care in rural Nigeria. These were categorized and noted in the margins of the transcripts. These categories were further grouped into a coding scheme and used to create sub-categories. Subcategories were further merged into larger subcategories with a more general description of the content. Similarities among the larger subcategories were noted and grouped to formulate main categories or themes. Multiple coders (SY, OU) worked independently to analyse the transcript, code the interview data using free codes and develop the various themes. The independent processes were examined for consistency during frequent discussions with the two coders (SY, OU). This was necessary to establish inter-rate reliability and ensure trustworthiness of the study. The co-authors audited the data analysis findings and reached a consensus on emerging themes. The socio-ecological theory of health behaviour emerged as an organizing framework for presenting the data. This theory asserts that human health behaviour is determined by the interplay of multiple levels of influence across individual, community and the broader institutional and policy realms [16]. Through this theory, this study explored the dynamic interactions of intrapersonal (individual), interpersonal and community, institutional and policy factors that influence the use of skilled pregnancy care. Themes and sub-themes were organised as follows: The authors adopted various strategies to ensure trustworthiness in this qualitative study following suggestions by Shenton 27. KIIs were structured to allow for iterative questioning including the use of probes to elicit detailed data and rephrasing questions to participants when necessary [26]. After data collection, FO and LN conducted member checks to ensure accuracy of the data. The coding process involved two coders (SY, OU) working independently to code the data and collaboratively to generate themes. The principal investigators FO, SY, and LN who have ample experience in reproductive health in sub-Saharan Africa audited the findings and provided feedback. All authors reached a consensus on emerging themes. In writing up the manuscript, the primary author (OU) provided thick descriptions of the phenonmenon of interest. Triangulation is important in promoting confirmability. This study approached triangulation via data sources by interviewing a wide range of informants [26]. In addition, selected quotes were chosen and reported to represent a typical response relative to the theme. To ensure confirmability, the decisions made in the research process including the research objectives and interpretation of findings are described in detail with examples of direct quotations to confirm interpretations [27].