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Background The presence of COVID-19 has led to the disruption of health systems globally, including essential reproductive, maternal, newborn and child health (RMNCH) services. This study aimed to assess the challenges faced by women who used RMNCH services in Nigeria’s epicentre, their satisfaction with care received during the COVID-19 pandemic and the factors associated with their satisfaction. Methods This cross-sectional survey was conducted in Lagos, southwest Nigeria among 1,241 women of reproductive age who had just received RMNCH services at one of twenty-two health facilities across the primary, secondary and tertiary tiers of health care. The respondents were selected via multi-stage sampling and face to face exit interviews were conducted by trained interviewers. Client satisfaction was assessed across four sub-scales: Health care delivery, health facility, interpersonal aspects of care and access to services. Bivariate and multivariate analyses were used to assess the relationship between personal characteristics and client satisfaction. Results About 43.51% of respondents had at least one challenge in accessing RMNCH services since the COVID-19 outbreak. Close to a third (31.91%) could not access service because they could not leave their houses during the lockdown and 18.13% could not access service because there was no transportation. The mean clients’ satisfaction score among the respondents was 43.25 (SD: 6.28) out of a possible score of 57. Satisfaction scores for the interpersonal aspects of care were statistically significantly lower in the PHCs and general hospitals compared to teaching hospitals. Being over 30 years of age was significantly associated with an increased clients’ satisfaction score (ß = 1.80, 95%CI: 1.10-2.50). Conclusion The COVID-19 lockdown posed challenges to accessing RMNCH services for a significant proportion of women surveyed. Although overall satisfaction with care was fairly high, there is a need to provide tailored COVID-19 sensitive inter-personal care to clients at all levels of care. Copyright:
This was a descriptive, cross-sectional survey conducted in Lagos, southwest Nigeria during the COVID-19 outbreak. Lagos State is divided into five administrative divisions namely Ikeja, Badagry, Ikorodu, Lagos and Epe. Health care delivery is structured along a three-tier system–tertiary, secondary and primary health care centres. The state has three public tertiary facilities which provide RMNCH services–Lagos University Teaching Hospital (LUTH), Lagos State University Teaching Hospital (LASUTH) and Federal Medical Centre, Ebute Metta. The state also has 26 secondary facilities (general hospitals) and 329 functional primary health care (PHC) facilities spread across the five administrative divisions, all of which provide RMNCH services i.e. integrated services for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood. The RMNCH services provided vary according to the level of care and include; 1) Clinical care: case management for sexually transmitted infections, post-abortion care, skilled obstetric care at birth and essential care for neonates, prevention of mother to child transmission of HIV, emergency obstetric care and immediate emergency care for newborn babies, case management of childhood and neonatal illness, care of children with HIV; 2) Outpatient and outreach services: family planning, prevention and management of sexually transmitted infections and HIV, antenatal care, postnatal care, childhood vaccination, nutrition and growth monitoring. The study population consisted of women of reproductive age (15–49 years) who had just received RMNCH services at one of the health facilities across the three tiers of care. Women were assessed to be eligible if they had accessed RMNCH services in the facility at least once during the COVID-19 outbreak in Lagos between 16th September 2020 and 12th October 2020. Those less than 18 years old were only included if they were emancipated, defined in this study as being married or living independently of parents. The minimum sample size of 400 was calculated using the Cochran’s formula and was based on 5% margin of error, 95% confidence interval, proportion (p) of 62.5% which represents overall satisfaction with MCH services in a hospital in southwest Nigeria [17], and 10% addition for non-response and recording errors. This sample size was tripled to account for design effect in using multiple sites making a sample size of 1,200 women. There was an equal allocation of the sample size to the three levels of care (i.e., 400 women per level of care). This was further allocated equally across the facilities for each level of care. Respondents were selected using a multi-stage sampling technique. At the first stage (facility level), the two teaching hospitals providing RMNCH services in Lagos State (LUTH and LASUTH) were purposively selected. Ten secondary facilities (two from each of the five administrative divisions) were selected by simple random sampling. Ten PHCs (two with the highest number of clients from each of the five administrative divisions) were selected purposively. At the participants level, consenting eligible participants were selected consecutively across all outpatient clinics providing RMNCH services until the sample size was attained. Exit interviews were conducted with eligible end-users of RMNCH at the selected facilities. A pretested, structured questionnaire was used by seven trained interviewers able to communicate in local languages to elicit information regarding socio-demography, challenges with accessing RMNCH services at the facilities and client satisfaction with these services since the COVID-19 epidemic in Lagos state. The client satisfaction items (S1 Questionnaire) were adapted from a validated tool to measure client-perceived quality of maternity services [18]. All questions were imputed in a form on the KoBoToolbox app (Harvard Humanitarian Initiative, Cambridge, Massachusetts, USA), which was the tool for data collection using smart phones. The instrument was pretested among 20 women of reproductive age in the Lagos environs and necessary adjustments were made to suit the local context. An item on access to credit was removed because it is not applicable to Lagos state health facilities. The research assistants observed strict COVID-19 safety rules such as use of face masks and encouragement of respondents to do same, hand hygiene and data collection in well-ventilated rooms and open spaces. The client satisfaction scales had 19 items in total and assessed satisfaction across four sub-scales: health care delivery, health facility, interpersonal aspects of care and access to services [18, 19]. The options and corresponding scores for these items were: not at all satisfied (score of 1), somewhat satisfied (score of 2) and completely satisfied (score of 3). Those that were not sure of the satisfaction of the specified item or for which the item did not apply were excluded from the analysis for that particular measure. Cronbach’s alpha was used to measure the internal consistency of the scale. The health care delivery sub-scale had 7 items with Cronbach alpha value of 0.72 and a possible range of scores between 1 to 21. The health facility sub-scale had 4 items with Cronbach alpha value of 0.73 and a possible range of 1 to 12. The sub-scale for interpersonal aspects of care had 6 items with a Cronbach alpha value of 0.80 and a possible range of 1 to 18. The access to services sub-scale had just 2 items which is less than the minimum of 3 items to calculate Cronbach alpha; it had a possible range of 1 to 6. Overall, the client satisfaction scale had a Cronbach alpha value of 0.86 with a range of 1 to 57. Univariate, bivariate and multivariate analyses were used to assess the relationship between the outcome variables and explanatory variables. At the univariate level, we estimated proportions for categorical variables and means and standard deviations for continuous variables. In bivariate analysis, we used one-way analysis of variance to determine statistically significant differences in mean scores across the three levels of care and the Bonferroni Procedure as a post-hoc test. Also, Student’s t-test was used to compare the mean client satisfaction scores across patients’ personal characteristics. This was followed by multiple linear regression to examine the association between personal characteristics and clients’ satisfaction. All independent variables in bivariate analyses with p-value <0.25 were included in the regression model and beta coefficient and 95% CI were computed for each predictor variable. The results were assessed to be significant at p-value <0.05. Data was analysed using STATA version SE15.1 (StataCorp, College Station, Texas, USA). Ethical approval for this study was obtained 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 the facilities was obtained from the Lagos State Health Services Commission and the Lagos State Primary Health Care Board. A waiver of signed consent was obtained from the ethics committee since the research presented minimal risk of harm to participants. Instead, verbal informed consent was obtained from all participants before any interview and documented by the research assistants on the data collection app. Their confidentiality was maintained by not using identifiers in the consent and data collection process.
