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

  • BMC Health Services Research, Volume 22, No. 1, Year 2022

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Study Justification:
– The study aimed to explore the experiences and perceptions of maternity healthcare workers in Lagos State, Nigeria, during the COVID-19 pandemic.
– The COVID-19 pandemic has posed challenges to the provision and access of essential maternity care in low-resilience health systems.
– Understanding the experiences and perceptions of maternity healthcare workers is crucial for improving the delivery of care during future outbreaks.
Study Highlights:
– The study identified two overarching themes: “Maternity care workers’ willingness and ability to work during the COVID-19 pandemic” and “Perceived impact of COVID-19 on women’s access and uptake of maternity care.”
– Negative influences on maternity care workers included fear and uncertainty, risk of infection, burnout, and transport difficulties. Positive influences included professional duty, faith, family, and employer support.
– Suggestions to improve the ability to work included providing adequate protective equipment, training, financial support, and workplace flexibility.
– The study highlighted reduced access and uptake of antenatal and immunization services by women, with challenges including overstretched health services, movement and cost barriers, and community fear of health facilities.
– Participants reported delayed healthcare seeking and unattended home births, emphasizing the need for community outreach to raise awareness for safe access to maternity services.
– Participants emphasized the responsibility of the government to improve staff welfare and implement public health campaigns.
Recommendations for Lay Readers and Policy Makers:
– Provide maternity care workers with adequate working conditions and training to rebuild public trust and improve access to maternity care during outbreaks.
– Ensure the availability of adequate protective equipment, training, financial support, and workplace flexibility for maternity care workers.
– Implement community outreach programs to raise awareness and address barriers to safe access to maternity services.
– Improve staff welfare and implement public health campaigns to enhance the resilience of the maternity care system during outbreaks.
Key Role Players:
– Maternity healthcare workers (midwives and traditional birth attendants)
– Government health departments and policymakers
– Primary health facilities
– Medical Officer of Health in each Local Government Area
– Lagos State Traditional Medicine Board
Cost Items for Planning Recommendations:
– Adequate protective equipment for maternity care workers
– Training programs for maternity care workers
– Financial support for maternity care workers
– Workplace flexibility measures
– Community outreach programs
– Public health campaigns
Please note that the cost items provided are for planning purposes and not actual costs. The actual budget would depend on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study that conducted individual, remote, semi-structured interviews with midwives and traditional birth attendants (TBAs) in Lagos State, Nigeria. The study followed the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines and used thematic analysis to identify patterns and themes in the data. The study provides insights into the experiences and perceptions of maternity healthcare workers during the COVID-19 pandemic in Lagos State. However, the evidence could be strengthened by providing more information about the sample size, recruitment process, and data saturation. Additionally, including direct quotes or examples from the interviews would enhance the credibility of the findings. To improve the evidence, future studies could consider increasing the sample size, conducting interviews in local languages to capture a wider range of perspectives, and involving participants in member checking to validate the findings.

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.

The study aimed to explore the experiences and perceptions of maternity healthcare workers in Lagos State, Nigeria, during the COVID-19 pandemic. The findings of the study identified several recommendations to improve access to maternal health:

1. Strengthening Maternity Care Worker Support: Providing adequate protective equipment, training, and financial support to maternity care workers can ensure their safety and enable them to provide quality care during the pandemic. Additionally, offering workplace flexibility can address challenges such as burnout and transport difficulties.

2. Community Outreach and Awareness: Conducting community outreach programs can raise awareness among women about the importance of accessing maternity care services safely during the pandemic. Addressing community fears of health facilities and providing information on the measures taken to ensure their safety can encourage women to seek timely care.

3. Improving Staff Welfare and Trust: Addressing issues of understaffing and mistrust in the underfunded maternity care system is crucial. Improving staff welfare, including fair compensation and working conditions, can help retain and attract skilled maternity care workers. Implementing public health campaigns to rebuild public trust in the healthcare system can also contribute to improved access to maternity care.

By implementing these recommendations, the resilience of the maternity care system can be enhanced during outbreaks like the COVID-19 pandemic. This can lead to improved access to maternal health services in Lagos State, Nigeria.
AI Innovations Description
Based on the findings of the study, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Maternity Care Worker Support: Provide adequate protective equipment, training, and financial support to maternity care workers. This will ensure their safety and enable them to provide quality care during the COVID-19 pandemic. Additionally, offering workplace flexibility can help address challenges such as burnout and transport difficulties.

2. Community Outreach and Awareness: Conduct community outreach programs to raise awareness among women about the importance of accessing maternity care services safely during the pandemic. Addressing community fears of health facilities and providing information on the measures taken to ensure their safety can encourage women to seek timely care.

3. Improving Staff Welfare and Trust: Address issues of understaffing and mistrust in the underfunded maternity care system. This can be achieved by improving staff welfare, including fair compensation and working conditions. Implementing public health campaigns to rebuild public trust in the healthcare system can also contribute to improved access to maternity care.

By implementing these recommendations, it is possible to enhance the resilience of the maternity care system during outbreaks like the COVID-19 pandemic, rebuild public trust, and improve access to maternal health services in Lagos State, Nigeria.
AI Innovations Methodology
The methodology used in this study aimed to explore the experiences and perceptions of maternity healthcare workers during the COVID-19 pandemic in Lagos State, Nigeria. The study utilized a qualitative research design, specifically a generic qualitative approach, to gather in-depth insights from midwives and traditional birth attendants (TBAs) through individual, remote, semi-structured interviews.

The study recruited participants through purposive and snowball sampling methods from primary health facilities in seven Local Government Areas (LGAs) of Lagos State. Skilled maternity care workers were purposively selected from the seven LGAs to ensure a diverse participant group based on age, gender, and level of maternity care experience. TBAs were also included through convenience sampling and snowball sampling approaches.

The interviews were conducted remotely using Zoom software by a primary researcher based in the UK. The interviews were audio-recorded and lasted between 30 to 90 minutes. An interview topic guide was developed based on the study aims, existing literature, and discussions with the research team. The primary researcher worked closely with a Nigerian researcher and public health doctor based in Lagos to develop and pilot the interview questions, as well as to address cultural differences and their impact on data collection.

Verbal informed consent was obtained from participants before the interviews, and a verbal questionnaire was administered to capture socio-demographic data and provide contextual information. Field notes were taken after each interview to reflect on initial impressions, data saturation, and potential themes. Thematic analysis was conducted using the framework method, which involved coding the transcripts, developing an analytical framework, charting and summarizing the data in a framework matrix, and identifying themes through iterative revisions.

The analysis process involved collaboration among members of the research team, including co-authors based in Nigeria and the UK, to enhance cultural integrity and maintain researcher reflexivity. QSR NVivo 12 software was used to manage the data.

The findings of the study were organized into two overarching themes: “Maternity care workers’ willingness and ability to work during the COVID-19 pandemic” and “Perceived impact of COVID-19 on women’s access and uptake of maternity care.” These themes provided insights into the challenges and facilitators faced by maternity healthcare workers and the impact of the pandemic on maternal and newborn healthcare.

The study was published in BMC Health Services Research in 2022, providing valuable insights into the experiences and perceptions of maternity healthcare workers during the COVID-19 pandemic in Lagos State, Nigeria.

Statistics:
Authors: 5
Identifiers:
DOI: 10.1186/s12913-022-08009-y
Research Areas:
Community Interventions, COVID, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce
Study Countries:
Nigeria
Study Design:
Cross Sectional Study, Exploratory Study, Grounded Theory
Study Approach:
Mixed-methods, Qualitative
Participants Gender:
Female
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