Preconception care practices in Nigeria: a descriptive qualitative study

Reproductive Health, Volume 17, No. 1, Year 2020

Interpretation

Background: Preconception care is a specialized care targeted at women of reproductive age before pregnancy to detect, treat or counsel them about pre-existing medical and social conditions that may militate against safe motherhood and positive pregnancy outcome. In spite of the known need for preconception care in Nigeria, routine preconception care services are not available in the country. This study explores existing preconception care practices in the country in order to encourage building on it and formalising it for inclusion in routine maternal and child health services in the country. Methods: Forty-one in-depth interviews and 10 focus group discussions were conducted in this descriptive qualitative study to explore the existing preconception care services from the perspectives of community members (women and men in the reproductive age group), community and religious leaders, health care professionals as well as policy makers. Thematic analysis was carried out using MAXQDA 2018. Results: Participants stated that there are no defined preconception care services in the health care system nor are there any structures or guidelines for preconception care in the country. Preconception care services are however provided when health workers perceive a need or when clients demand for it. The services provided include health information, education and counselling, treatment modification, medical check-up and screening. Outside of the health system, there are some traditional, religious and other practices with similar bearing to preconception care which the participants believed could be included as preconception care services. These include premarital counselling services by religious bodies, family life and HIV education within the secondary school system and some screening and outreach services provided by non-governmental and some governmental agencies. Conclusion: There is a need to provide structure and guidelines for preconception care services in the country so that the services can be properly streamlined. This structure can also involve practices that are currently not within the health system. This study used a qualitative descriptive approach. The qualitative descriptive approach provides direct descriptions of events or phenomena as presented by study participants staying as close as possible to the data with minimal interpretation or attempts at theory development [33–35]. In this study, we provide a description of the different preconception practices and services in Nigeria from the perspectives of the different groups of participants. The Nigerian health system operates at three levels—primary, secondary and tertiary—managed respectively by the local government, state and federal authorities in a concurrent manner [36]. Within this context, there is a rural–urban and north–south disparity in education, socio-economic opportunities and in access to health services [36]. The urban south has better access to health workers and health services and this translates to better health indices including better reproductive health outcomes [36, 37]. The study was carried out in Ibadan North Local Government Area (LGA) of Oyo State, an urban LGA in southwest Nigeria, on the premise that the population is better informed and can provide information on the array of existing preconception care practices to jumpstart the discussion on the need for the service in the country. Ibadan North LGA has all three levels of the health system represented including the University College Hospital, Ibadan, a tertiary centre. There are two secondary health facilities, one private and one government-owned—the Adeoyo Maternity Hospital as well as 10 primary healthcare centres (PHCs)—one located in each of the 10 political wards. All the health facilities provide maternal and child health services with the primary health centres giving preventive and some curative services while the secondary and tertiary health facilities are referral centres providing specialist services. Participants in this study were women and men in their peak reproductive ages (18–49 years and 18–59 years, respectively) and community leaders from Yemetu Ward 3, in the selected LGA. Yemetu Ward 3 was purposively selected because of its proximity to the tertiary and secondary health facilities in addition to having a PHC. The community leaders were the representatives of the community on the Ward Health Committee that provides oversight to the PHC in the ward. Christian clergy in the community were selected with the assistance of the branch office of the Christian Association of Nigeria within the community while Muslim clergy were identified with the help of the male community leader. Health care providers involved in provision of maternal and child health services and those who provided care for chronic medical conditions that can affect pregnancy outcomes were also interviewed for this study. They included health care workers at the primary (3), secondary (5) and tertiary health care levels (13 specialist physicians and 5 nurses covering 10 different medical specialities—Obstetrics and Gynaecology [Ob/Gyn], Paediatrics, Public Health, Endocrinology, Family Medicine, Haematology, Cardiology, Neurology, Nephrology and Psychiatry). The variations in the number of health workers at the different levels was patterned after the staff distribution at each level. In addition, the national and state Ministries, Departments and Agencies that cover maternal and child health related programs were identified and policy makers from relevant units and departments were interviewed. Participants in this study were selected purposefully as being able to provide the needed information. Men and women in the community were selected to provide information on existing cultural/traditional practices for improving preconception health. Health workers in the specialities selected are either directly involved in maternal and child health care (Ob/Gyn, Paediatrics, Public Health and Family Medicine) or have patients whose medical conditions may require preconception care if within the reproductive age group. The policy makers were selected from the Ministries, Departments and Agencies that provide oversight to maternal and child health services and related programs at the national and state levels. These were the Ministry of Health, Ministry of Education, Ministry of Women Affairs, Ministry of Youth and Sports Development and the National and State Primary Health Care Development Agencies. The community and religious leaders were selected on the basis of their involvement in providing counselling to young people while the community members were selected as being potential users of preconception care services. The community leaders assisted in recruiting the women and men. The women and men FGDs listed in Table Table11 were further disaggregated by educational level—less than junior secondary education and junior secondary education and above. The interviews at the community level held at locations within the community chosen by the study participants while the health workers and policy makers interviews held in the participants’ offices. Study population and method of data collection 4 focus group discussions Single—2 groups Married—2 groups 4 focus group discussions Single—2 groups Married—2 groups 2 key informant interviews One woman One man 2 focus group discussions Christians Muslims Interview guides were developed for the study following a review of preconception care literature. Content validation of the instruments was done by two experts in qualitative research after which the instruments were pretested and ambiguous questions were removed or revised. Open-ended questions explored the participants’ awareness and opinions about preconception care, and description of existing preconception care services that they know of. A description of preconception care as found in the literature was provided and participants were asked if they knew of any such services and where they were provided. For the purpose of the research, preconception care was described “as a special type of care provided for women and men of reproductive age before pregnancy to detect, treat or counsel them about pre-existing medical and social conditions that can endanger pregnancy. The goal is to ensure parents are in optimal state of health before pregnancy occurs. It includes screening, counselling and treatment/management of pre-existing medical conditions as well as reproductive life planning.” The interviews were conducted in English or Yoruba (the local language depending on the participants’ preference) by eight trained research assistants who were Masters in Public Health students at the University of Ibadan, Nigeria who had prior experience in qualitative data collection. A one-day training was conducted for the research assistants to familiarise them with the interview guides and concept of preconception care. Interview guides had been translated into Yoruba and back translated to ensure consistency of meaning with the aid of a professional service. The interviews lasted between 30 min and 1 h. Interviews were recorded digitally and transcribed verbatim. To ensure that the transcripts correctly captured the interviews, the first author read through each transcript while listening to the audio recordings. Transcripts were imported into MAXQDA 2018 for coding and thematic analysis. An initial set of codes were derived inductively from reading four of the transcripts, one each from the different groups of participants. Two independent coders (not co-authors) coded the initial set of transcripts along with the first author. The codes thus generated were reviewed and intercoder agreement reached between all three coders. The codes which came from recurring ideas and patterns found during multiple readings of the transcripts were merged into themes and applied to the rest of the transcripts with modifications as necessary in the course of the analysis. Where necessary, explanations of the terms used by the participants is provided while redundant words such as “erm” and “uhm” are deleted for clarity. We used the SRQR checklist as a guide in writing this article [38]. Ethical clearance for the study was obtained from the University of Ibadan/University College Hospital (UI/UCH) Institution Review Board (Clearance number UI/EC/17/0390) and the Wits Human Research Ethics Committee (Medical) (Clearance number M171054). All participants were provided with information sheets containing details of the study. Participation was voluntary. All willing participants appended the consent form by signature or thumbprint for participation in the study as well as for audio recording of the interviews. To maintain confidentiality, all transcripts were deidentified and labelled with codes.

AI Digest

Study Justification:

– Preconception care is important for ensuring safe motherhood and positive pregnancy outcomes.
– Routine preconception care services are not currently available in Nigeria.
– This study aims to explore existing preconception care practices in Nigeria and encourage the formalization of these practices for inclusion in routine maternal and child health services.

Highlights:

– The study found that there are currently no defined preconception care services or guidelines in the Nigerian health care system.
– Preconception care services are provided on an ad hoc basis when health workers perceive a need or when clients demand it.
– Existing services include health information, education and counseling, treatment modification, medical check-ups, and screening.
– Traditional, religious, and other practices with similarities to preconception care were identified and could be included as part of formal preconception care services.

Recommendations:

– There is a need to provide structure and guidelines for preconception care services in Nigeria.
– The structure should include practices that are currently outside of the health system.
– Formalizing preconception care services will help streamline and improve the quality of care provided.

Key Role Players:

– Health care professionals (including obstetricians/gynecologists, pediatricians, public health specialists, family medicine practitioners, etc.)
– Community and religious leaders
– Policy makers from relevant government departments and agencies (Ministry of Health, Ministry of Education, Ministry of Women Affairs, Ministry of Youth and Sports Development, National and State Primary Health Care Development Agencies)

Cost Items for Planning Recommendations:

– Development of guidelines and protocols for preconception care services
– Training and capacity building for health care professionals
– Public awareness campaigns and education materials
– Integration of preconception care services into existing maternal and child health programs
– Monitoring and evaluation of preconception care services implementation
Please note that the above cost items are general suggestions and may vary depending on the specific context and needs of Nigeria.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a descriptive qualitative study, which provides direct descriptions of preconception care practices in Nigeria. The study used in-depth interviews and focus group discussions to gather data from various stakeholders, including community members, health care professionals, and policy makers. The findings highlight the lack of defined preconception care services in the country and the need for structure and guidelines to streamline these services. The study provides valuable insights into existing practices and potential areas for improvement. However, the abstract does not mention the sample size or the representativeness of the participants, which could affect the generalizability of the findings. To improve the evidence, future studies could consider increasing the sample size and ensuring a more diverse representation of participants from different regions of Nigeria. Additionally, including quantitative data alongside qualitative findings could provide a more comprehensive understanding of preconception care practices in the country.

Abstract

This study used a qualitative descriptive approach. The qualitative descriptive approach provides direct descriptions of events or phenomena as presented by study participants staying as close as possible to the data with minimal interpretation or attempts at theory development [33–35]. In this study, we provide a description of the different preconception practices and services in Nigeria from the perspectives of the different groups of participants. The Nigerian health system operates at three levels—primary, secondary and tertiary—managed respectively by the local government, state and federal authorities in a concurrent manner [36]. Within this context, there is a rural–urban and north–south disparity in education, socio-economic opportunities and in access to health services [36]. The urban south has better access to health workers and health services and this translates to better health indices including better reproductive health outcomes [36, 37]. The study was carried out in Ibadan North Local Government Area (LGA) of Oyo State, an urban LGA in southwest Nigeria, on the premise that the population is better informed and can provide information on the array of existing preconception care practices to jumpstart the discussion on the need for the service in the country. Ibadan North LGA has all three levels of the health system represented including the University College Hospital, Ibadan, a tertiary centre. There are two secondary health facilities, one private and one government-owned—the Adeoyo Maternity Hospital as well as 10 primary healthcare centres (PHCs)—one located in each of the 10 political wards. All the health facilities provide maternal and child health services with the primary health centres giving preventive and some curative services while the secondary and tertiary health facilities are referral centres providing specialist services. Participants in this study were women and men in their peak reproductive ages (18–49 years and 18–59 years, respectively) and community leaders from Yemetu Ward 3, in the selected LGA. Yemetu Ward 3 was purposively selected because of its proximity to the tertiary and secondary health facilities in addition to having a PHC. The community leaders were the representatives of the community on the Ward Health Committee that provides oversight to the PHC in the ward. Christian clergy in the community were selected with the assistance of the branch office of the Christian Association of Nigeria within the community while Muslim clergy were identified with the help of the male community leader. Health care providers involved in provision of maternal and child health services and those who provided care for chronic medical conditions that can affect pregnancy outcomes were also interviewed for this study. They included health care workers at the primary (3), secondary (5) and tertiary health care levels (13 specialist physicians and 5 nurses covering 10 different medical specialities—Obstetrics and Gynaecology [Ob/Gyn], Paediatrics, Public Health, Endocrinology, Family Medicine, Haematology, Cardiology, Neurology, Nephrology and Psychiatry). The variations in the number of health workers at the different levels was patterned after the staff distribution at each level. In addition, the national and state Ministries, Departments and Agencies that cover maternal and child health related programs were identified and policy makers from relevant units and departments were interviewed. Participants in this study were selected purposefully as being able to provide the needed information. Men and women in the community were selected to provide information on existing cultural/traditional practices for improving preconception health. Health workers in the specialities selected are either directly involved in maternal and child health care (Ob/Gyn, Paediatrics, Public Health and Family Medicine) or have patients whose medical conditions may require preconception care if within the reproductive age group. The policy makers were selected from the Ministries, Departments and Agencies that provide oversight to maternal and child health services and related programs at the national and state levels. These were the Ministry of Health, Ministry of Education, Ministry of Women Affairs, Ministry of Youth and Sports Development and the National and State Primary Health Care Development Agencies. The community and religious leaders were selected on the basis of their involvement in providing counselling to young people while the community members were selected as being potential users of preconception care services. The community leaders assisted in recruiting the women and men. The women and men FGDs listed in Table Table11 were further disaggregated by educational level—less than junior secondary education and junior secondary education and above. The interviews at the community level held at locations within the community chosen by the study participants while the health workers and policy makers interviews held in the participants’ offices. Study population and method of data collection 4 focus group discussions Single—2 groups Married—2 groups 4 focus group discussions Single—2 groups Married—2 groups 2 key informant interviews One woman One man 2 focus group discussions Christians Muslims Interview guides were developed for the study following a review of preconception care literature. Content validation of the instruments was done by two experts in qualitative research after which the instruments were pretested and ambiguous questions were removed or revised. Open-ended questions explored the participants’ awareness and opinions about preconception care, and description of existing preconception care services that they know of. A description of preconception care as found in the literature was provided and participants were asked if they knew of any such services and where they were provided. For the purpose of the research, preconception care was described “as a special type of care provided for women and men of reproductive age before pregnancy to detect, treat or counsel them about pre-existing medical and social conditions that can endanger pregnancy. The goal is to ensure parents are in optimal state of health before pregnancy occurs. It includes screening, counselling and treatment/management of pre-existing medical conditions as well as reproductive life planning.” The interviews were conducted in English or Yoruba (the local language depending on the participants’ preference) by eight trained research assistants who were Masters in Public Health students at the University of Ibadan, Nigeria who had prior experience in qualitative data collection. A one-day training was conducted for the research assistants to familiarise them with the interview guides and concept of preconception care. Interview guides had been translated into Yoruba and back translated to ensure consistency of meaning with the aid of a professional service. The interviews lasted between 30 min and 1 h. Interviews were recorded digitally and transcribed verbatim. To ensure that the transcripts correctly captured the interviews, the first author read through each transcript while listening to the audio recordings. Transcripts were imported into MAXQDA 2018 for coding and thematic analysis. An initial set of codes were derived inductively from reading four of the transcripts, one each from the different groups of participants. Two independent coders (not co-authors) coded the initial set of transcripts along with the first author. The codes thus generated were reviewed and intercoder agreement reached between all three coders. The codes which came from recurring ideas and patterns found during multiple readings of the transcripts were merged into themes and applied to the rest of the transcripts with modifications as necessary in the course of the analysis. Where necessary, explanations of the terms used by the participants is provided while redundant words such as “erm” and “uhm” are deleted for clarity. We used the SRQR checklist as a guide in writing this article [38]. Ethical clearance for the study was obtained from the University of Ibadan/University College Hospital (UI/UCH) Institution Review Board (Clearance number UI/EC/17/0390) and the Wits Human Research Ethics Committee (Medical) (Clearance number M171054). All participants were provided with information sheets containing details of the study. Participation was voluntary. All willing participants appended the consent form by signature or thumbprint for participation in the study as well as for audio recording of the interviews. To maintain confidentiality, all transcripts were deidentified and labelled with codes.

Materials

N/A

Innovations

Based on the study “Preconception care practices in Nigeria: a descriptive qualitative study,” the following recommendations can be developed into innovations to improve access to maternal health:

1. Establish structured and formalized preconception care services in Nigeria, including guidelines and protocols for interventions, screenings, and counseling topics.

2. Provide training and capacity building programs for healthcare professionals on preconception care to ensure they have the necessary knowledge and skills.

3. Integrate preconception care services into routine maternal and child health services at all levels of the healthcare system.

4. Conduct community engagement activities to raise awareness about the importance of preconception care and its potential benefits.

5. Collaborate with non-governmental organizations (NGOs) to expand the reach of preconception care services.

6. Establish a system for monitoring and evaluating the implementation of preconception care services to ensure their effectiveness.

Implementing these recommendations can help improve access to preconception care and ultimately enhance maternal health outcomes in Nigeria.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study “Preconception care practices in Nigeria: a descriptive qualitative study” is to establish structured and formalized preconception care services in the country. Currently, routine preconception care services are not available in Nigeria, and there are no defined structures or guidelines for preconception care. However, the study found that some preconception care services are provided when health workers perceive a need or when clients demand it. These services include health information, education and counseling, treatment modification, medical check-ups, and screening.

To improve access to maternal health, it is recommended to develop a comprehensive preconception care program that includes the following elements:

1. Establish guidelines and protocols: Develop clear guidelines and protocols for preconception care services, outlining the recommended interventions, screenings, and counseling topics. These guidelines should be evidence-based and tailored to the Nigerian context.

2. Training and capacity building: Provide training and capacity building programs for healthcare professionals on preconception care. This will ensure that healthcare providers have the necessary knowledge and skills to deliver quality preconception care services.

3. Integration into existing healthcare services: Integrate preconception care services into routine maternal and child health services at all levels of the healthcare system, including primary, secondary, and tertiary care facilities. This will ensure that preconception care becomes a standard part of healthcare delivery.

4. Community engagement and awareness: Conduct community engagement activities to raise awareness about the importance of preconception care and its potential benefits. This can be done through community meetings, health education campaigns, and collaboration with community leaders and religious organizations.

5. Collaboration with non-governmental organizations (NGOs): Partner with NGOs that are already providing preconception care-related services, such as screening and outreach programs, to expand the reach of preconception care services. This collaboration can help leverage existing resources and expertise.

6. Monitoring and evaluation: Establish a system for monitoring and evaluating the implementation of preconception care services to ensure their effectiveness and identify areas for improvement. This can include tracking key indicators, conducting regular assessments, and collecting feedback from service users.

By implementing these recommendations, Nigeria can improve access to preconception care and ultimately enhance maternal health outcomes.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, a mixed-methods approach can be used. Here is a brief description of the methodology:

1. Quantitative data collection: Conduct a survey to assess the current level of access to maternal health services in Nigeria. This can include indicators such as the percentage of women receiving preconception care, the availability of structured preconception care services, and the knowledge and awareness of preconception care among healthcare providers and the general population. The survey can be administered to a representative sample of healthcare facilities, healthcare providers, and women of reproductive age.

2. Qualitative data collection: Conduct in-depth interviews and focus group discussions with key stakeholders, including healthcare providers, policymakers, community leaders, and women of reproductive age. The interviews and discussions should explore their perceptions and experiences related to preconception care, including barriers to access, existing practices, and the potential impact of implementing the recommendations. Thematic analysis can be used to identify common themes and patterns in the data.

3. Development of a simulation model: Based on the findings from the quantitative and qualitative data collection, develop a simulation model to estimate the potential impact of implementing the recommendations on improving access to maternal health. The model should consider factors such as the number of healthcare facilities offering preconception care, the training and capacity building of healthcare providers, the integration of preconception care into existing healthcare services, community engagement and awareness activities, collaboration with NGOs, and monitoring and evaluation mechanisms.

4. Data analysis and interpretation: Analyze the data collected from the survey, interviews, and focus group discussions to assess the current situation and identify gaps and challenges in access to maternal health services. Use the simulation model to estimate the potential impact of implementing the recommendations on improving access to maternal health. Interpret the findings to understand the potential benefits and limitations of the recommendations.

5. Recommendations and policy implications: Based on the findings from the data analysis and simulation model, develop recommendations for policymakers and stakeholders on how to improve access to maternal health services in Nigeria. Consider the feasibility, cost-effectiveness, and sustainability of the recommendations. Advocate for policy changes and resource allocation to support the implementation of the recommendations.

By using this methodology, researchers and policymakers can gain insights into the current state of access to maternal health services in Nigeria and the potential impact of implementing the recommendations. This can inform evidence-based decision-making and help prioritize interventions to improve maternal health outcomes.

Authors & Co-Authors

Statistics:

Citations: 5

Authors: 2

Identifiers:

DOI: 10.1186/s12978-020-01030-6

Research Areas:

Community Interventions, 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, Exploratory Study, Grounded Theory, Phenomenological Study

Study Approach:

Qualitative

Participants Gender:

Male & Female