Persistent barriers to care; a qualitative study to understand women’s experiences in areas served by the midwives service scheme in Nigeria

Background: The Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented. Methods: A qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach. Results: The majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care. Conclusions: Our research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors. A qualitative study was undertaken as part of an impact evaluation of the MSS conducted 5 years after the introduction of the programme [10]. The impact evaluation assessed how the MSS has affected antenatal care, institutional deliveries or assistance from a skilled provider, postnatal visits and maternal and newborn health outcomes compared to areas where the MSS has not yet been implemented. A theory of change1 was developed by the research team to guide the evaluation design and understand the underlying mechanisms through which the MSS might result in improvements in maternal, newborn and child health (MNCH) outcomes (Fig. 1). The qualitative study explored the underlying mechanisms of action, as hypothesized by the research team, through which the MSS could lead to improvements in MNCH outcomes: (1) increased access to skilled birth attendance; (2) improvements (including perceived) in the quality of care; and (3) changes in potential service users’ attitudes to seeking care (Fig. 1). Proposed theory of change for the MSS Data collection took place between June 2014 and January 2015, around nine MSS PHCs in three study states: Enugu, Kwara and Kano. The three states were selected from different geopolitical zones which had varying maternal mortality ratios (rated as ‘very high’ (North West), ‘high’ (North Central) and ‘moderate’ (South East) maternal mortality) [4]. One state in each of these zones was then selected in order to achieve a range according to maternal health service utilisation and population characteristics (Table 1). Selected characteristics of chosen states in 2008 before introduction of MSS [2] The selection of PHCs was informed by clinic survey data collected as part of the impact evaluation. The PHCs were selected purposively to capture PHCs with apparently differing success in terms of recruitment and retention of midwives and uptake of services [10]. Variables examined included; electricity supply, number and type of staff employed and their length of employment, number of deliveries in the previous six months, number of infant and maternal mortalities as well as qualitative observations made in the clinic survey. PHCs were chosen with contrasting characteristics in order to try to capture a range of conditions where things might be going well or less well, or based on a striking feature for example a very high infant mortality rate. In Enugu state, one PHC was selected from the comparison group to provide contrast. An overview of the selected MSS PHCs is provided in Additional file 2. In each PHC catchment area semi-structured interviews were undertaken with women who had given birth within six months to the date of interview, midwives employed through the MSS and policymakers (local and state level) and focus group discussions (FGDs) with other community members; WDC, men and potential service users (women with and without children). The focus of the interviews varied by participant (Table 2); interviews with women focused on their interaction with care services throughout pregnancy, childbirth and subsequent care seeking as well as their views and experience relating to accessibility and quality of the care available. Each FGD group was asked for their own views and experiences of the MSS, what may be working well and less well and also the extent to which they felt the MSS was meeting the needs of women and wider communities. An overview of the questions asked is provided in Additional file 3. Overview qualitative data collection: participant groups and focus of interviews and focus groups We sought to sample 45 women (15 in each state), 15 midwives (five in each state), nine state policy makers (three in each state) and nine local policy makers (three in each state). Participants were selected purposively to ensure a range of characteristics; for women this included place gave birth (to select those who delivered at PHC and elsewhere), age, number of children, occupation and place of residence, while for midwives this included for example age, length of time since qualified and length of time been employed by MSS. Policy makers were identified based on their level of involvement in the MSS. Interviews followed a semi-structured format. Interview guides were pretested in the selected states to ensure cultural sensitivity. Interviews were undertaken by locally trained researchers in the local language, which varied by site. Potential participants were approached by the researchers, who explained the purpose of the study and answered any questions before seeking verbal consent for participating in the study. Participation was voluntary and participants were free to withdraw from the study at any time without giving a reason. Interviews were conducted at the policy makers’ offices, while for midwives and women they were conducted in the vicinity of the PHC or home, although effort was made to hold them in a space away from the actual PHC to reduce interruptions and allow the participant to speak freely. The FGDs were organized by participant group (women, men, community leaders) to ensure that participants were able to talk freely. Potential participants were identified with help from a village guide, who was also responsible for convening the groups. The village guide was selected by the researchers based on their ability to identify relevant participants. The FGDs followed a semi-structured format. Two locally trained researchers moderated the FGDs to ensure smooth running and also to record interactions within the group. FGDs were held at a time and place convenient for participants. Participants were compensated for their travel and refreshments were provided. With consent from participants, interviews and FGDs were audio-recorded and later transcribed verbatim and translated into English by the locally trained researchers. Formal back translation was not undertaken but the transcripts were reviewed by the fieldwork coordinator in each state for accuracy. Ethical approval for this study was granted by institutional Review Boards at RAND, Kano State Hospitals Management Board, Aminu Kano Teaching Hospital, and University of Nigeria Enugu. A systematic and rigorous analysis was undertaken using a method based on the constant comparative approach [11], supported by QSR Nvivo software. The data were read and re-read separately and initial codes identified independently by two researchers (JE/EP). The coding frame was agreed by both researchers and coding undertaken by a single researcher (JE). Initially ‘open codes’ were applied to the data to represent the significance of sections of text. These were incrementally grouped into organizing categories, or ‘themes’, which were modified and checked constantly in order to develop a coding frame with explicit specifications. The coding frame, influenced partly by the research questions but particularly by ideas arising during the data collection, was used to systematically assign the data to the thematic categories [12]. Data from different participant groups were analysed separately and then compared for areas of convergence and divergence. Anonymized quotations from the data have been used to illustrate the key themes and subthemes. Respondents and FGD participants are identified first by the state (E = Enugu, Ka = Kano, Kw = Kwara) and PHC catchment area where the interview/FGD took place (1, 2 or 3), and secondly by the participant type, (SPm = State Policy maker, LPm = Local Government, M = midwife, WH = woman who gave birth at home, WC = women gave birth in PHC, FG = focus group). The focus of the analysis was to understand women’s views and experiences of having given birth in an area where MSS had been implemented.