Barriers and facilitators of access to maternal, newborn and child health services during the first wave of COVID-19 pandemic in Nigeria: findings from a qualitative study

Background: COVID-19 pandemic may have affected the utilization of maternal and newborn child health services in Nigeria but the extent, directions, contextual factors at all the levels of healthcare service delivery in Nigeria is yet to be fully explored. The objective of the study was to explore the barriers and facilitators of access to MNCH services during the first wave of COVID-19 pandemic in Nigeria. Methods: A qualitative study was conducted among different stakeholder groups in 18 public health facilities in Nigeria between May and July,2020. In-depth interviews were conducted among 54 study participants (service users, service providers and policymakers) selected from across the three tiers of public health service delivery system in Nigeria (primary health centers, secondary health centers and tertiary health centers). Coding of the qualitative data and identification of themes from the transcripts were carried out and thematic approach was used for data analyses. Results: Barriers to accessing MNCH services during the first wave of COVID-19-pandemic in Nigeria include fear of contracting COVID-19 infection at health facilities, transportation difficulties, stigmatization of sick persons, lack of personal protective equipment (PPE) /medical commodities, long waiting times at hospitals, shortage of manpower, lack of preparedness by health workers, and prioritization of essential services. Enablers to access include the COVID-19 non-pharmacological measures instituted at the health facilities, community sensitization on healthcare access during the pandemic, and alternative strategies for administering immunization service at the clinics. Conclusion: Access to MNCH services were negatively affected by lockdown during the first wave of COVID-19 pandemic in Nigeria particularly due to challenges resulting from restrictions in movements which affected patients/healthcare providers ability to reach the hospitals as well as patients’ ability to pay for health care services. Additionally, there was fear of contracting COVID-19 infection at health facilities and the health systems inability to provide enabling conditions for sustained utilization of MNCH services. There is need for government to institute alternative measures to halt the spread of diseases instead of lockdowns so as to ensure unhindered access to MNCH services during future pandemics. This may include immediate sensitization of the general public on modes of transmission of any emergent infectious disease as well as training of health workers on emergency preparedness and alternative service delivery models. The study utilized a qualitative study design to explore the perceptions of users of healthcare facilities, health workers, and policymakers on how COVID-19 has shaped the utilization of MNCH services as well as other contextual factors contributing to the projected views across six states of Nigeria. The states were chosen purposefully to represent the six (6) geopolitical zones of the country. Three states namely Abuja, Lagos and Kano had high cases for COVID-19 while the other three (Enugu, Taraba and Bayelsa) had fewer cases of Covid-19. Three Local Government Areas (LGA) were selected from each state representing three senatorial districts. The selection of states with high and few cases was considered necessary to explore contextual differences in barriers and facilitators to accessing MNCH services in these states. The states, health facilities and the number of covid-19 cases in the states as of 17th May 2020 when data collection began is as shown in Table ​Table11. List of participating states, health facilities and number of cases of COVID-19 in the states A total of 54 in-depth interviews (IDIs) were conducted across all six (6) states with 9 interviews in each state comprising of 3 policymakers, 3 service providers and 3 service users. These were spread equally across the three levels of health care systems (Primary health care, secondary health care and tertiary healthcare) in the states. The state study coordinators scheduled and confirmed the dates and time of the planned IDIs with the study participants after obtaining informed written consent. The participants were also informed that the interview will be recorded during the informed consent process. Interviews were facilitated by experienced interviewers over the phone based on prior schedules by study coordinators. All interviews were conducted with study participants using their personal phones, although this was not a criterion in the selection process. The interviewers (three female and three male) were experienced qualitative researchers with extensive training and expertise conducting research across Nigeria. They worked with members of the core research team to schedule interviews with the respondents while determining the best time for the interview to take place. The study participants were informed about the purpose of the study and were invited to participate in the interview, which lasted for approximately 20 to 30 min. All interviews were conducted in English language using an IDI guide designed specifically for this study for each of the stakeholder groups (Maternal and child health service users, service providers and policy makers across all levels of healthcare system). In-depth interviews (IDI) guides captured barriers and facilitators that influenced access to MNCH services and service delivery during COVID-19. The final research tool was tested amongst each stake holder group before utilization for the study (See Supplementary file 1). The conceptual framework for understanding the impact of COVID-19 on MNCH service utilization in this study was the three delays model. The delay model was used to explore delays in access to MNCH services in three different but closely related phases [12–14]. The interviews were recorded digitally, transcribed verbatim, and transferred to NVivo12 software for analysis. The codebook development process entailed a review of all the transcripts by four researchers (OD, ES, JO GOA) who contributed to the development of a thematic framework of codes through consensus. Thematic analysis was used as an analytical strategy to explore patterns and themes within the data. Thematic analysis involves the identification, analysing and reporting of patterns in data and provides the basis for many other forms of qualitative analysis [15]. The process of thematic analysis involves careful identification of themes achieved through familiarization and immersion in data [16]. The steps involved in the analysis process include familiarization with the data; initial coding and development of a codebook; search for themes by reviewing, recoding and categorization of data; review of themes; and definition of final themes [15]. A deductive analytical approach was used in this study because the general aim of thematic analysis was to test a previous theory in a different situation [17, 18]. Some codes were determined as priori codes and others emerged during the coding process. As part of the coding process, the research team explored the data until data saturation was achieved when additional interviews coded did not change the structure/content of the codebook. The process of identifying themes highlighted contextual situations that underpin perceptions and experiences expressed in the data. The themes were organized using the three (3) delay models to explore the contextual factors that shaped utilization as well as enablers and barriers of access.