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Background: The early phase of the COVID-19 pandemic led to significant disruptions in provision of maternal, newborn, and child health (MNCH) services, especially in low- and middle-income countries (LMICs) with fragile health systems, such as Nigeria. Measures taken to ‘flatten the curve’ such as lockdowns, curfews, travel restrictions, and suspension of public services inadvertently led to significant disruptions in provision of essential health services. In these countries, health facility leaders are directly responsible for driving changes needed for service delivery. Objective: To explore perspectives of health facility leaders in Lagos, Nigeria, on solutions and adaptations implemented to support MNCH service provision during the early phase of the COVID-19 pandemic. Methods: Key informant interviews were remotely conducted with purposively sampled 33 health facility leaders across primary, secondary, and tertiary public health facilities in Lagos between July and November 2020. Following verbatim transcription of recordings, data familiarization, and coding, thematic analysis was used to synthesize data. Results: Health facility leaders scaled down or discontinued outpatient MNCH services and elective surgeries. However, deliveries, newborn, immunization, and emergency services continued. Service provision was reorganized with long and staggered patient appointments, collapsing of wards and modification of health worker duty rosters. Some secondary and tertiary facilities leveraged technology like WhatsApp, webinars, and telemedicine to support service provision. Continuous capacity-building for health workers through training, motivation, psychological support, and atypical sourcing of PPE was instituted to be able to safely maintain service delivery. Conclusion: Health facility leaders led the frontline of the COVID-19 response. While they took to implementing global and national guidelines within their facilities, they also pushed innovative facility-driven adaptations to address the indirect effects of COVID-19. Insights gathered provide lessons to foster resilient LMIC health systems for MNCH service provision in a post-COVID-19 world.
Lagos State is the economic nerve centre of Nigeria. With a population of 21 million people, it is the most populous state in Nigeria. The State has also been the epicentre of the COVID-19 pandemic in the country with over 22,000 laboratory-confirmed cases and 220 deaths, making up 14% and 11% of national figures respectively [14]. The lockdown in Lagos lasted for 108 days (complete lockdown: March 30–May 3, 2020 [35 days] and gradual easing lockdown: May 5–July 15, 2020 [73 days]) [15]. The different phases of the lockdown entailed limitation of local and interstate travel, public gathering, opening of non-essential businesses, and curfews as guided by the State’s Emergency Response Committee. As a result of the high number of COVID-19 cases in the State, a lot of resources were diverted towards management of the COVID-19 response [16]. Pre-pandemic, the State was implementing strategic plans in response to some sub-optimal indicators of MNCH including 76% facility-based delivery, 73% of women with postnatal check within two days of birth, maternal mortality ratio of 555 per 100,000 live births, neonatal mortality rate of 29 per 1,000 live births, and under-five mortality rate of 50 per 1000 live births [17,18]. In Lagos State, public sector health service provision is tiered (primary, secondary, and tertiary). There are 329 primary healthcare centres (PHCs) at the primary level, 27 general hospitals at the secondary level and five tertiary healthcare facilities (including two teaching hospitals and one federal medical centre that provide MNCH services) [19]. The state has 57 councils under five administrative zones with 38 to 145 PHCs and two to nine general hospitals per zone. Although concerns relating to unresponsiveness of service provision have been highlighted, women using MNCH services in Lagos public hospitals have reported that they were satisfied with the competency of health personnel and equipment in the higher-level facilities [20]. Health facility leaders who were responsible for operations in public hospitals and PHCs across the State were invited to partake in the study via phone calls. At the primary health care level, we targeted medical officers of health, apex nurses, and apex community health officers across five councils with a total of 39 PHCs under their supervision. At the secondary level, we recruited medical directors and heads of department/units providing MNCH services in five general hospitals. To get a good spread, the councils with their corresponding PHCs and the general hospitals were selected from the five administrative zones in the state. At the tertiary level, we used the two teaching hospitals providing MNCH services and targeted Chairmen Medical Advisory Committees (CMACs) and heads of departments/units. Key informant interviews (KIIs) were conducted with health facility leaders between July and November 2020. This was the period after the gradual easing of the lockdown in the state [15]. A predesigned standard operating protocol was used to guide the process of data collection. The KIIs were conducted remotely via Zoom (Zoom Video Communications, San Jose, California, United States) by the principal investigator (MB). All the KIIs were audio-recorded and lasted between 32–47 minutes. Reflective notes were taken to supplement transcripts. Piloted topic guides were used to collect data. These topic guides included several open-ended questions that focused on experience and challenges of interviewees in leading service provision during the pandemic. During the KIIs, as expected of robust qualitative research, trustworthiness of the research was a focus [21]. The interviewer made efforts to establish rapport with the interviewees and verification of assertions of interviewees was done to ensure an accurate understanding had been captured by the interviewer. Data collection continued until data saturation was reached. Audio recordings from the KIIs were transcribed verbatim. A thematic analysis was conducted using Braun and Clarke’s six steps for thematic analysis: becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining, and naming themes, and producing the report [22]. An inductive approach was taken in generating the codes. Open coding was conducted to ensure that no relevant information of the data was missed, in line with the exploratory approach taken for this analysis. Analysis was performed with the aid of computer-assisted qualitative data analysis software, NVivo 10 (QSR International, Memphis, Tennessee, USA). Illustrative quotes were extracted from the transcripts to reflect the core message within the key emerging themes. Ethical approval was received from the Health Research and Ethics Committee of Lagos University Teaching Hospital (LUTHHREC/EREV/0620/64). Social approval was obtained from the Lagos State Ministry of Health and permission to access health facility leaders was obtained from the Lagos State Health Service Commission, the Lagos State Primary Health Care Board, and the heads of facilities. Participation in the study was entirely voluntary. A waiver of signed informed consent was obtained from the ethics committee as the research was deemed to present minimal risk of harm to interviewees. Instead, verbal informed consent was obtained from the interviewees as well as consent for audio recording. The audio recordings were saved in a password-protected laptop and deleted after transcriptions after completed. Confidentiality of interviewees was maintained by not using identifiers. No financial incentive was offered.
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