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Background: While Primary Health Care has been designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths in Nigeria, available evidence suggests that pregnant women in rural communities often do not use Primary Health Care Centres for skilled care. The objective of this study was to investigate the reasons why women do not use PHC for skilled pregnancy care in rural Nigeria. Methods: Qualitative data were obtained from twenty focus group discussions conducted with women and men in marital union to elicit their perceptions about utilisation of maternal and child health care services in PHC centres. Groups were constituted along the focus of sex and age. The group discussions were tape-recorded, transcribed verbatim and analyzed thematically. Results: The four broad categories of reasons for non-use identified in the study were: 1) accessibility factors – poor roads, difficulty with transportation, long distances, and facility not always open; 2) perceptions relating to poor quality of care, including inadequate drugs and consumables, abusive care by health providers, providers not in sufficient numbers and not always available in the facilities, long waiting times, and inappropriate referrals; 3) high costs of services, which include the inability to pay for services even when costs are not excessive, and the introduction of informal payments by staff; and 4) Other comprising partner support and misinterpretation of signs of pregnancy complications. Conclusion: Addressing these factors through adequate budgetary provisions, programs to reduce out-of-pocket expenses for maternal health, adequate staffing and training, innovative methods of transportation and male involvement are critical in efforts to improve rural women’s access to skilled pregnancy care in primary health care centres in the country.
The study was part of a formative research project intended to identify elements to include in the design of an intervention for improving the access of rural women to skilled pregnancy care in rural Nigeria. An interpretive description design was used given the exploratory nature of the study, while the analysis and presentation followed the Standards for Reporting Qualitative Research (SRQR). The study was conducted in Esan South East (ESE) and Etsako East (ETE) Local Government Areas (LGA) of Edo State in southern Nigeria. Both LGAs are located in the rural areas of the state, adjacent to River Niger, with Estako East in the northern part of the Edo State part of the river, while Esan South East is in the southern part. Administratively, each LGA comprises of 10 political/health wards and there are several communities in each ward. Subsistence farming is the major source of livelihood in the communities. The two LGAs have a total population of 313,717persons, with ESE accounting for 167,721 and ETE accounting for 145,996. PHC centres are the principal source of maternity health care in the two LGAs. However, ESE LGA has one General Hospital in Ubiaja (headquarters of the LGA) while ETE has one General Hospital in Agenebode (the LGA administrative headquarters) and another in nearby Fugar City. Several private hospitals also exist in both LGAs that offer maternal and child health services of various degrees of quality and cost. These public and private facilities are used as additional to the existing PHC centres or for referral maternal health services. A quantitative survey of 1408 women conducted in the two LGAs as part of the formative research had revealed that many of the women do not use the PHC centres for antenatal care and childbirth [21]. To explore deeper reasons why women do not use PHC centres for skilled pregnancy care, we conducted focus group discussions with various categories of women and men in various communities in the LGAs. A total of 20 focus group discussions (FGDs) with men and women in marital union were conducted from July 29 to August 16, 2017, to elicit their preferences, beliefs and perceptions about maternal health, and utilisation of maternal and child health care services in the primary health care facilities. Ten FGDs were held in each Local Government area. The groups were organized along the focus of sex and age to enable participants to speak freely as the presence of the opposite sex and older persons may compromise the quality and accuracy of data [22, 23]. Two groups were constituted for each of the following age categories: women less than 30 years old, women aged 31–45 years, men less than 40 years, men aged 40–54 and men aged 55 and over. The number of FGDs conducted for each age category was pre-determined based on the investigators’ knowledge of the communities. Each group consisted of 6–12 participants who were recruited by a gatekeeper through face-to-face contact. Many of the FGDs were conducted in Pidgin English and a few in the local language. The group discussions were tape recorded. The data were collected by trained field assistants and supervised by an experienced researcher. Female field assistants moderated the groups for women whereas male assistants moderated for the male groups and each group had a note-taker. The FGDs were conducted in convenient locations in the communities chosen by the participants and each discussion lasted between 60 and 90 min. A focus group discussion guide was prepared by the investigators and pre-tested in a community which has similar characteristics with the study locations. A few new questions were added while some sentences were rephrased following the pretest. The FGDs focused on where women in the communities access maternal care and the reasons why they do not use the PHC centres located in their communities. Probes included affordability, distance, and transportation among others. Ways to improve the access of pregnant women and children to health care offered by PHC facilities were also solicited in order to obtain deeper insights into the reasons that women do not use the PHC facilities for pregnancy care. The FGDs were tape-recorded and transcribed verbatim. The FGDs that were conducted in the local language and Pidgin English were transcribed by speakers of the language who are also proficient in the English language. A code list was generated by two authors from the research questions and other codes consisted of those emerging from the narratives. Computer-assisted software (Atlas.ti 6.2) was used to code and organize the codes into relevant themes. The analysis consisted of a description of the content and form following identified relevant themes. To ensure consistency and credibility of the data and the findings, member check, source, and investigator triangulation and peer review were employed. The findings were presented to selected respondents for confirmation in an intervention design meeting with the community members and other stakeholders. Thematic saturation was confirmed by the team of researchers involved in the data collection, transcription and analysis. A reasoned consensus on the emerging themes was achieved after depth discussion of the findings among the investigators. Ethical approval for the study was obtained from the National Health Research Ethics Committee (NHREC) of Nigeria – protocol number NHREC/01/01/2007–10/04/2017. The communities were contacted through lead contact persons, and permission to undertake the study was obtained from the Heads (Odionwere) of the communities. The participants were informed of the purpose of the study, and individual written informed consent was obtained from them. They were assured of the confidentiality of information obtained, and that such information would only be used for the study and not for other purposes. No names or specific contact information were obtained from the study participants. Only men and women that agreed to participate in the fully explained study were enlisted in the study.
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