Perceptions and experiences of maternity care workers during COVID-19 pandemic in Lagos State, Nigeria; a qualitative study

Background: The COVID-19 (coronavirus disease 2019) pandemic challenges provision and access to essential maternity care in low-resilience health systems. The aim of this study was to explore maternity healthcare workers’ experiences of, and perceptions about providing maternity care during the COVID-19 outbreak in Lagos State, Nigeria. Methods: This qualitative study conducted individual, remote, semi-structured interviews with midwives and traditional birth attendants (TBAs). Eligible participants spoke English, and provided maternity care during COVID-19 in Lagos, Nigeria. Participants were recruited via purposive and snowball sampling, from primary health facilities in seven Local Government Areas of Lagos State. Interview transcripts were analysed thematically following the framework method. Results: Sixteen midwives (n = 11) and TBAs (n = 5) were interviewed from March to April 2021. Two overarching themes were identified from the data. ‘Maternity care workers’ willingness and ability to work during the COVID-19 pandemic’ outlined negative influences (fear and uncertainty, risk of infection, burnout, transport difficulties), and positive influences (professional duty, faith, family and employer support). Suggestions to improve ability to work included adequate protective equipment, training, financial support, and workplace flexibility. ‘Perceived impact of COVID-19 on women’s access and uptake of maternity care’ highlighted reduced access and uptake of antenatal and immunisation services by women. Challenges included overstretched health services, movement and cost barriers, and community fear of health facilities. Participants reported delayed healthcare seeking and unattended home births. Midwives and TBAs identified a need for community outreach to raise awareness for women to safely access maternity services. Participants highlighted the responsibility of the government to improve staff welfare, and to implement public health campaigns. Conclusions: Despite disruption to maternity care access and delivery due to COVID-19, midwives and TBAs in Lagos remained committed to their role in caring for women and babies. Nevertheless, participants highlighted issues of understaffing and mistrust in Lagos’ underfunded maternity care system. Our findings suggest that future resilience during outbreaks depends on equipping maternity care workers with adequate working conditions and training, to rebuild public trust and improve access to maternity care. The aim of this study was to explore maternity healthcare workers’ experiences of, and perceptions about providing maternity care during the COVID-19 pandemic in Lagos State, Nigeria. Specific research objectives were to understand the role of midwives and TBAs during the pandemic; barriers and facilitators to delivery of care; and the perceived impact of COVID-19 on maternal and newborn healthcare. This generic qualitative study design was driven by the research aims of exploring experiences and perceptions, and as such did not draw on a priori theory, as is consistent with a generic approach [28, 29]. In-depth interviews were used to explore maternity care workers’ experiences of the COVID-19 pandemic. This research study conforms to Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines [30]. This study was developed in collaboration with a senior public health doctor and researcher with experience conducting qualitative research in Lagos, Nigeria. As the most populous and commercial hub in the country, Lagos State was the epicentre of COVID-19 cases in the country [4]. Due to the local researcher’s prior knowledge and research experience in Lagos State, it was chosen as an appropriate study setting with maternity healthcare workers experiencing the frontline pandemic response. According to UN-Habitat and international development agencies’ estimates, Lagos State had about 24.6 million inhabitants in 2015 [31]. Lagos has a diverse population with many ethnic groups, and commonly spoken languages are Yoruba, Pidgin English, and English [30]. The state comprises 20 Local Government Areas (LGAs), which can be categorised as urban, peri-urban, or rural [5]. Skilled maternity care workers (not TBAs) were purposively selected from seven LGAs (Lagos Mainland, Surulere, Ikeja, Alimosho, Kosofe, Badagry, Oshodi-Isolo), chosen to provide a range of population and geographical contexts [32]. The Medical Officer of Health in each LGA purposively identified maternity care workers in these areas, to provide a diverse participant group according to age, gender, and level of maternity care experience. For TBAs, a convenience sampling approach was taken [33]: study information was shared with all TBAs in the local researcher’s existing professional network with the permission of the Lagos State Traditional Medicine Board [32]. Due to a low response rate, this was supplemented by a snowball sampling approach, where participants were asked to identify colleagues who may be willing to take part, and share study information with them [34]. Eligible participants were over 18 years old, and able to speak English. Potential participants were provided with an information leaflet that outlined the study information, and were invited to interview at their chosen venue, or a venue provided by the local researcher. Reasons for non-participation included being too busy due to involvement in the COVID-19 vaccination programme that commenced in March 2021. Remote (Zoom software), semi-structured interviews were conducted by the primary researcher based in the UK from March to April 2021. Interviews were in English, audio-recorded and lasted 30–90 minutes. An interview topic guide (see Additional file 1) was developed based on study aims, existing literature and discussion with the research team [35]. The data was collected by [initials anonymised for peer review], a UK-based female medical student and novice qualitative researcher, who is not Nigerian. The work was undertaken as part of a programme of international health study, and pre-COVID this would have involved an academic placement in Lagos and face-to-face fieldwork for a research project. Due to the pandemic, international travel was not possible. To mitigate the lack of local exposure, [initials anonymised for peer review] worked in close contact with [initials anonymised for peer review], a female Nigerian researcher and public health doctor based in Lagos, to develop and pilot the interview questions, and to discuss and reflect on cultural differences and their impact on data collection. The project provided resources (medical student time, research costs funding) to deliver the research, and formal training in qualitative methods was provided. This was complemented by extensive supervision and support of the research process by two academic public health doctors with qualitative expertise (one in Nigeria, one in the UK). Before interview, verbal informed consent was recorded, and the interviewer administered a verbal questionnaire to capture participants’ socio-demographic data and contextualise data. Field notes were written after each interview to reflect on initial impressions and potential themes, data saturation, and to adjust the topic guide. An inductive approach was used to generate findings from the data. Thematic analysis was conducted following the framework method outlined by Gale et al [36], to provide a systematic method to identify patterns across and within cases. Firstly, the primary researcher performed verbatim transcription to facilitate familiarisation of data. Three members of the research team independently coded three transcripts, then collaboratively developed a working analytical framework which grouped codes into categories. The primary researcher coded the remaining transcripts, adopting an iterative approach to revise the framework in consultation with other researchers. Data was charted and summarised in a framework matrix in Microsoft Excel, to interrogate data, develop themes, and make within- and cross-case comparisons, and identify deviant cases. Analytical summaries of themes were developed and refined in the context of the research question. Analytical triangulation was used as developing themes were discussed with the research team. Our multicultural, team-based approach to data analysis involved co-authors based in Nigeria and the UK to enhance cultural integrity and maintain researcher reflexivity to examine how researcher’s beliefs, judgements, and practices influenced construction of findings [37]. Data was managed using QSR NVivo 12 [38]. Following data analysis, transcripts were not returned to respondents for comments and corrections.