Men’s perception of barriers to women’s use and access of skilled pregnancy care in rural Nigeria: A qualitative study

Reproductive Health, Volume 16, No. 1, Year 2019

Interpretation

Background: Greater paternal engagement is positively associated with improved access to and utilization of maternal services. Despite evidence that male involvement increased uptake of maternal and child services, studies show that few men are participating in MNCH programs. Community leaders have long been engaged in public health promotion in rural settings and have been shown to mobilize communities to enhance changes in cultural practices related to public health. With the ultimate goal of increasing men’s involvement in maternal health, this study seeks to understand men’s perceptions of community and health systems barriers to maternal access and usage of skilled care in rural Edo, Nigeria. Methods: This qualitative study involved the analysis of data collected from community conversations with male elders in Etsako East and Esan South East Local Government Areas of Edo State, Nigeria. Community conversations participants (n = 128) comprised of elders between the ages of 50-101. A total of 9 community conversations were conducted. Discussions were audio recorded, transcribed and imported into Atlas.ti 6.2 for content analysis. Results: Men’s perceptions of barriers to maternal use of skilled care are presented in two overarching themes: community systems and health systems. Three sub themes were generated as community systems barriers to maternal healthcare use, they include: gender roles, traditional treatment and policy changes. Three sub themes emerged under health system barriers and they include: cost of health facilities, dissatisfaction with facilities and distance from facilities. Conclusion: Findings suggest that community elders are not only in a good position to influence men’s behavior, they are also a source of information to policy makers on strategies to overcome barriers to maternal health, especially at the community level. Furthermore, community elders need support to enact regulations that will promote men’s involvement in maternal health, thereby increasing maternal use of skilled care. This study was conducted using an interpretive description design. As a qualitative methodology, interpretive description is located within existing health-related knowledge of researchers and participants, which serves as a foundation for new inquiry [42]. It rejects the notion of a single rigid reality and assumes instead, context bound and inter subjectively constructed realities through social interactions [43, 44]. Interpretive description provides patterns and variations for individual and common human experiences through which researchers and participants co-construct a narrative that can inform clinical practice. This paper draws on qualitative data collected in rural areas of Edo State, Nigeria with a focus on understanding the community and health actors that serve as barriers to maternal access and use of MNCH services. This is a part of a larger original study conducted in rural Edo state, which seeks to identify barriers to equity of access, accessibility and utilization of primary health care services (PHCs) for maternal and newborn health care. The larger study is designed as a community based, multi-site cluster randomized trial using a mixed method approach; a randomized control trial (RCT) and analysis of qualitative data from focus groups, key informant interviews and community conversations (CC) with male elders. Nigeria is Africa’s most populous country and has a population of 180 million people. With an annual population growth rate of 3%, Nigeria is projected to have the second-largest population increase in the world by 2050 [45]. The country is divided into six geopolitical zones and made up of 36 States. About 50% of Nigeria’s population reside in rural areas [46]. This study was conducted in Edo State, one of Nigeria’s thirty-six States. More specifically, the study was carried out in Esan South East and Etsako East local government areas (LGAs) of Edo, both of which are in the rural parts of the State. Male elders from the community were targeted participants in this study and the reason is two-fold. First, the authors acknowledge that achieving positive social change within a community requires identifying and involving institutions within which powers are exercised [47]. In rural communities such as Esan and Etsokan, the sphere of influence of community elders remains strong. They are the gateway to the community and ensuring their buy-in improves the trust relationship between the communities and researchers. Second, male elders can be instrumental in reconstructing cultural norms within which men’s attitudes towards maternal health are formed. There is evidence that community leaders have helped overcome the reluctance of adult males to participate in maternal health related programs. Therefore, while it is easier to only engage men or husbands of pregnant women, it is important to engage men in communities who have the power to influence community attitudes [48]. Furthermore, this study acknowledges that male elders have the influence to provide a supportive social environment wherein men are encouraged and not stereotyped, when they deviate from traditional male behaviour. Participants were recruited through purposeful sampling, which considered locally accepted ways of communication. The primary inclusion criteria were age 50 and over and recognition in the community as an opinion leader. Recruitment was continued until data saturation was reached [49]. In rural communities such as Esan and Etsako, face-to-face communication is not only a common means of transferring information, but also a means for governance and social interactions. A gatekeeper who is an indigene of the communities helped to identify elders who meet the inclusion criteria and invited them to the conversation through face-to-face contact. The consent of the traditional ruler in each community was sought and obtained before each CC was conducted. This study conducted community conversations with male elders in the community. This methodology is participatory, facilitates buy-in on issues deemed culturally sensitive, and is potentially transformative; preparing supportive groundwork for a useful intervention that would raise awareness and mobilize social change. Studies have shown that community conversations can be agents of change. This approach has helped raise awareness and create consensus about other culturally sensitive issues including HIV testing and prevention, human trafficking, female gender mutilation, and child marriage [50]. We believe that the open and public dialogue could challenge and shift community-level norms about gender and maternal health. The conversations were designed to explore community elders’ understanding of maternal health, community and systems barriers to access and usage of skilled pregnancy care and to proffer potential solutions. Community conversations encourage reflection and discussion; it assumes a conversational format to explore the interpretation barriers to maternal health and ways to reduce it. The CCs carried out by trained investigators were conducted in Pidgin English and a few in the local language. The fieldwork took place from July 29 to August 162,017. A total of 9 CCs were conducted with 6 in Esan South East LGA and 3 in Etsako East LGA. The number of participants in each CC ranged from 12 to 21. Discussions in the CCs lasted between 60 and 90 min and ended when no further issues arose (point of saturation). Conversations were audio-recorded, transcribed verbatim and reviewed for clarity and accuracy of the transcription. Any identifying information for each participant was altered to protect their privacy; they were assigned unique codes instead. Participants’ responses were either transcribed verbatim if they responded in English or translated if they responded in Pidgin English and the local language. Translated quotations are noted in square braces. Literal translation (word-by-word) was used to preserve participants’ responses and provide readers with an understanding of the mentality of the participants [51]. To improve trustworthiness of the data, the data was transcribed by co-authors who are proficient in both Pidgin English and English language. Other coauthors with proficiencies in both languages re-examined the translated transcripts and screened it for errors. A guide was prepared for the CCs which focused specifically on men’s perception of barriers to women’s use and access of skilled care. A sample of some of the issues discussed with participants during the CCs includes: The ethical clearance approval needed for the project was obtained from the National Health Research Ethics Committee (NHREC) after the submission of the study protocol. The project ethical clearance certificate was approved on April 18, 2017, with NHREC Approval Number: NHREC/01/01/2007–18/04/2017. To ensure confidentiality, all personal identifiers were removed from transcripts. Written informed consent was obtained from all participants prior to their participation. In keeping with the interpretive design of the study, data analysis was iterative and on going throughout the data collection phase, with each process informing the other. Thematic exploration of participants’ perceptions was carried out through a holistic and line-by-line reading of the transcripts. The authors immersed themselves in the transcripts and recordings to identify themes. Given the iterative nature of the data analysis, saturation was achieved when no more patterns or themes emerged from the data. The authors endeavoured to capture and present a holistic understanding of community and health system factors that hindered maternal healthcare access and use. An open coding was done with Atlas.ti. A code list was first generated deductively from the literature and additional codes were added to the list from the themes that emerged from the data. The codes were merged to generate themes which were classified into two broad categories for the narrative: 1) community systems barriers with themes such as gender roles, and traditional treatment among others, and 2) health systems barriers with themes such as cost of service, dissatisfaction with health facilities etc.

AI Digest

Study Justification:

– Greater paternal engagement is associated with improved access to and utilization of maternal services.
– Few men are participating in maternal and child health programs.
– Community leaders have been shown to mobilize communities to enhance changes in cultural practices related to public health.
– Understanding men’s perceptions of barriers to maternal access and usage of skilled care can inform strategies to overcome these barriers and increase maternal use of skilled care.

Study Highlights:

– Qualitative study conducted in rural Nigeria.
– Data collected from community conversations with male elders.
– Two overarching themes emerged: community systems barriers and health systems barriers.
– Community systems barriers include gender roles, traditional treatment, and policy changes.
– Health systems barriers include cost of health facilities, dissatisfaction with facilities, and distance from facilities.
– Findings suggest that community elders can influence men’s behavior and provide information to policy makers.
– Community elders need support to enact regulations that promote men’s involvement in maternal health.

Study Recommendations:

– Increase community elders’ involvement in promoting men’s engagement in maternal health.
– Address gender roles and traditional treatment as barriers to maternal healthcare use.
– Improve the cost, quality, and accessibility of health facilities.
– Reduce distance barriers to accessing skilled care.

Key Role Players:

– Community leaders and elders
– Policy makers
– Health facility administrators
– Researchers and data analysts

Cost Items for Planning Recommendations:

– Training and capacity building for community leaders and elders
– Awareness campaigns and community mobilization efforts
– Improvement of health facilities and services
– Transportation and logistics for reaching remote areas
– Monitoring and evaluation of interventions
– Research and data collection expenses

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a qualitative study involving community conversations with male elders in rural Nigeria. The study provides detailed information on the barriers to women’s use and access of skilled pregnancy care, including community and health systems factors. The qualitative data was collected through audio recordings, transcribed, and analyzed using content analysis. The study also acknowledges the importance of community elders in influencing men’s behavior and suggests actionable steps to promote men’s involvement in maternal health. To improve the evidence, the abstract could include information on the limitations of the study and the implications of the findings for policy and practice.

Abstract

This study was conducted using an interpretive description design. As a qualitative methodology, interpretive description is located within existing health-related knowledge of researchers and participants, which serves as a foundation for new inquiry [42]. It rejects the notion of a single rigid reality and assumes instead, context bound and inter subjectively constructed realities through social interactions [43, 44]. Interpretive description provides patterns and variations for individual and common human experiences through which researchers and participants co-construct a narrative that can inform clinical practice. This paper draws on qualitative data collected in rural areas of Edo State, Nigeria with a focus on understanding the community and health actors that serve as barriers to maternal access and use of MNCH services. This is a part of a larger original study conducted in rural Edo state, which seeks to identify barriers to equity of access, accessibility and utilization of primary health care services (PHCs) for maternal and newborn health care. The larger study is designed as a community based, multi-site cluster randomized trial using a mixed method approach; a randomized control trial (RCT) and analysis of qualitative data from focus groups, key informant interviews and community conversations (CC) with male elders. Nigeria is Africa’s most populous country and has a population of 180 million people. With an annual population growth rate of 3%, Nigeria is projected to have the second-largest population increase in the world by 2050 [45]. The country is divided into six geopolitical zones and made up of 36 States. About 50% of Nigeria’s population reside in rural areas [46]. This study was conducted in Edo State, one of Nigeria’s thirty-six States. More specifically, the study was carried out in Esan South East and Etsako East local government areas (LGAs) of Edo, both of which are in the rural parts of the State. Male elders from the community were targeted participants in this study and the reason is two-fold. First, the authors acknowledge that achieving positive social change within a community requires identifying and involving institutions within which powers are exercised [47]. In rural communities such as Esan and Etsokan, the sphere of influence of community elders remains strong. They are the gateway to the community and ensuring their buy-in improves the trust relationship between the communities and researchers. Second, male elders can be instrumental in reconstructing cultural norms within which men’s attitudes towards maternal health are formed. There is evidence that community leaders have helped overcome the reluctance of adult males to participate in maternal health related programs. Therefore, while it is easier to only engage men or husbands of pregnant women, it is important to engage men in communities who have the power to influence community attitudes [48]. Furthermore, this study acknowledges that male elders have the influence to provide a supportive social environment wherein men are encouraged and not stereotyped, when they deviate from traditional male behaviour. Participants were recruited through purposeful sampling, which considered locally accepted ways of communication. The primary inclusion criteria were age 50 and over and recognition in the community as an opinion leader. Recruitment was continued until data saturation was reached [49]. In rural communities such as Esan and Etsako, face-to-face communication is not only a common means of transferring information, but also a means for governance and social interactions. A gatekeeper who is an indigene of the communities helped to identify elders who meet the inclusion criteria and invited them to the conversation through face-to-face contact. The consent of the traditional ruler in each community was sought and obtained before each CC was conducted. This study conducted community conversations with male elders in the community. This methodology is participatory, facilitates buy-in on issues deemed culturally sensitive, and is potentially transformative; preparing supportive groundwork for a useful intervention that would raise awareness and mobilize social change. Studies have shown that community conversations can be agents of change. This approach has helped raise awareness and create consensus about other culturally sensitive issues including HIV testing and prevention, human trafficking, female gender mutilation, and child marriage [50]. We believe that the open and public dialogue could challenge and shift community-level norms about gender and maternal health. The conversations were designed to explore community elders’ understanding of maternal health, community and systems barriers to access and usage of skilled pregnancy care and to proffer potential solutions. Community conversations encourage reflection and discussion; it assumes a conversational format to explore the interpretation barriers to maternal health and ways to reduce it. The CCs carried out by trained investigators were conducted in Pidgin English and a few in the local language. The fieldwork took place from July 29 to August 162,017. A total of 9 CCs were conducted with 6 in Esan South East LGA and 3 in Etsako East LGA. The number of participants in each CC ranged from 12 to 21. Discussions in the CCs lasted between 60 and 90 min and ended when no further issues arose (point of saturation). Conversations were audio-recorded, transcribed verbatim and reviewed for clarity and accuracy of the transcription. Any identifying information for each participant was altered to protect their privacy; they were assigned unique codes instead. Participants’ responses were either transcribed verbatim if they responded in English or translated if they responded in Pidgin English and the local language. Translated quotations are noted in square braces. Literal translation (word-by-word) was used to preserve participants’ responses and provide readers with an understanding of the mentality of the participants [51]. To improve trustworthiness of the data, the data was transcribed by co-authors who are proficient in both Pidgin English and English language. Other coauthors with proficiencies in both languages re-examined the translated transcripts and screened it for errors. A guide was prepared for the CCs which focused specifically on men’s perception of barriers to women’s use and access of skilled care. A sample of some of the issues discussed with participants during the CCs includes: The ethical clearance approval needed for the project was obtained from the National Health Research Ethics Committee (NHREC) after the submission of the study protocol. The project ethical clearance certificate was approved on April 18, 2017, with NHREC Approval Number: NHREC/01/01/2007–18/04/2017. To ensure confidentiality, all personal identifiers were removed from transcripts. Written informed consent was obtained from all participants prior to their participation. In keeping with the interpretive design of the study, data analysis was iterative and on going throughout the data collection phase, with each process informing the other. Thematic exploration of participants’ perceptions was carried out through a holistic and line-by-line reading of the transcripts. The authors immersed themselves in the transcripts and recordings to identify themes. Given the iterative nature of the data analysis, saturation was achieved when no more patterns or themes emerged from the data. The authors endeavoured to capture and present a holistic understanding of community and health system factors that hindered maternal healthcare access and use. An open coding was done with Atlas.ti. A code list was first generated deductively from the literature and additional codes were added to the list from the themes that emerged from the data. The codes were merged to generate themes which were classified into two broad categories for the narrative: 1) community systems barriers with themes such as gender roles, and traditional treatment among others, and 2) health systems barriers with themes such as cost of service, dissatisfaction with health facilities etc.

Materials

N/A

Innovations

Based on the description provided, here are some potential innovations that could improve access to maternal health:

1. Male Engagement Programs: Develop and implement programs that specifically target men and aim to increase their involvement in maternal health. This could include education and awareness campaigns, workshops, and support groups for expectant fathers.

2. Community Mobilization: Work with community leaders and elders to mobilize communities and promote changes in cultural practices related to maternal health. This could involve engaging community leaders in public health promotion activities and empowering them to advocate for increased access to skilled pregnancy care.

3. Policy Changes: Advocate for policy changes that address barriers to maternal healthcare access. This could include advocating for policies that reduce the cost of health facilities, improve the quality of care, and increase the availability of healthcare services in rural areas.

4. Improving Health Facility Infrastructure: Invest in improving the infrastructure of health facilities in rural areas, including ensuring that facilities are adequately equipped and staffed. This could help address issues related to dissatisfaction with facilities and distance from facilities.

5. Financial Support: Provide financial support or subsidies for maternal healthcare services, particularly for low-income individuals who may struggle to afford the cost of care. This could help address the barrier of cost of health facilities.

6. Training and Capacity Building: Provide training and capacity building programs for healthcare providers to improve the quality of care and ensure that they are equipped with the necessary skills and knowledge to provide comprehensive maternal healthcare services.

7. Health Information Systems: Implement health information systems that can track and monitor maternal health indicators, identify gaps in access and utilization, and inform decision-making and resource allocation.

8. Community Education and Awareness: Conduct community education and awareness campaigns to increase knowledge and understanding of the importance of skilled pregnancy care. This could involve disseminating information through various channels, such as community meetings, radio programs, and mobile health applications.

9. Transportation Support: Address transportation barriers by providing transportation support for pregnant women to access healthcare facilities. This could include establishing transportation services or partnerships with existing transportation providers to ensure that women can easily access care.

10. Telehealth and Mobile Health Solutions: Utilize telehealth and mobile health solutions to improve access to maternal healthcare services in remote or underserved areas. This could involve providing virtual consultations, remote monitoring, and health education through mobile applications or telecommunication platforms.

These innovations aim to address the barriers identified in the study and improve access to skilled pregnancy care in rural Nigeria.

AI Innovations Description

The study titled “Men’s perception of barriers to women’s use and access of skilled pregnancy care in rural Nigeria: A qualitative study” aims to understand men’s perceptions of barriers to maternal access and usage of skilled care in rural Edo, Nigeria. The study was conducted using an interpretive description design, which is a qualitative methodology that explores context-bound and inter-subjectively constructed realities through social interactions.

The study involved community conversations with male elders in Etsako East and Esan South East Local Government Areas of Edo State, Nigeria. A total of 128 male elders participated in 9 community conversations. The conversations were audio recorded, transcribed, and analyzed using content analysis in Atlas.ti 6.2.

The findings of the study identified two overarching themes of barriers to maternal healthcare use: community systems and health systems. Under community systems barriers, three sub-themes emerged: gender roles, traditional treatment, and policy changes. Under health systems barriers, three sub-themes were identified: cost of health facilities, dissatisfaction with facilities, and distance from facilities.

The study suggests that community elders play a crucial role in influencing men’s behavior and can provide valuable insights to policymakers on strategies to overcome barriers to maternal health at the community level. The findings also highlight the need for support to empower community elders to enact regulations that promote men’s involvement in maternal health, ultimately increasing maternal use of skilled care.

The study acknowledges the importance of engaging male elders in rural communities due to their influence and ability to reconstruct cultural norms related to men’s attitudes towards maternal health. The participants were recruited through purposeful sampling, considering locally accepted ways of communication, and data saturation was reached.

The study used community conversations as a participatory and potentially transformative methodology to raise awareness and mobilize social change. It is believed that open and public dialogue can challenge and shift community-level norms about gender and maternal health.

To ensure confidentiality, all personal identifiers were removed from the transcripts, and written informed consent was obtained from all participants. Data analysis was iterative and ongoing throughout the data collection phase, with thematic exploration of participants’ perceptions conducted through a holistic and line-by-line reading of the transcripts.

Overall, this study provides valuable insights into the barriers to maternal health access and usage in rural Nigeria and highlights the importance of engaging community elders in promoting men’s involvement in maternal health. The findings can inform clinical practice and contribute to efforts aimed at improving access to maternal health services.

AI Innovations Methodology

Based on the description provided, here are some potential recommendations for innovations to improve access to maternal health:

1. Male engagement programs: Develop and implement programs that specifically target men and aim to increase their involvement in maternal health. This could include education and awareness campaigns, community outreach programs, and support groups for expectant fathers.

2. Community mobilization: Work with community leaders, including male elders, to mobilize communities and promote changes in cultural practices that may hinder access to maternal health services. This could involve engaging community leaders in advocacy efforts, training them to be champions for maternal health, and involving them in decision-making processes.

3. Policy changes: Advocate for policy changes that address barriers to maternal health access and utilization. This could include advocating for improved healthcare infrastructure in rural areas, reducing the cost of maternal health services, and ensuring that healthcare facilities are adequately staffed and equipped.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using a combination of quantitative and qualitative data. Here is a brief outline of a possible methodology:

1. Baseline data collection: Collect data on the current state of access to maternal health services in the target area. This could include data on the number of women accessing prenatal care, the number of skilled birth attendants available, and the distance to the nearest healthcare facility.

2. Intervention implementation: Implement the recommended innovations, such as male engagement programs, community mobilization efforts, and policy changes. Monitor the implementation process and collect data on the reach and effectiveness of each intervention.

3. Data collection post-intervention: After a specified period of time, collect data on the impact of the interventions on access to maternal health services. This could include data on changes in the number of women accessing prenatal care, improvements in the availability of skilled birth attendants, and changes in the distance to healthcare facilities.

4. Data analysis: Analyze the collected data to assess the impact of the interventions. This could involve comparing pre- and post-intervention data, conducting statistical analyses, and identifying trends and patterns in the data.

5. Evaluation and recommendations: Based on the data analysis, evaluate the effectiveness of the interventions in improving access to maternal health services. Identify any gaps or areas for improvement and make recommendations for future interventions or policy changes.

It is important to note that this is a general outline and the specific methodology may vary depending on the context and resources available.

Author

Dima Health

Statistics:

Citations: 18

Identifiers:

DOI: 10.1186/s12978-019-0752-3

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Nigeria

Study Design:

Cross Sectional Study, Grounded Theory, Narrative Study, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male & Female