Challenges in access and satisfaction with reproductive, maternal, newborn and child health services in Nigeria during the COVID-19 pandemic: A cross-sectional survey

PLoS ONE, Volume 16, No. May, Year 2021

Interpretação

Background The presence of COVID-19 has led to the disruption of health systems globally, including essential reproductive, maternal, newborn and child health (RMNCH) services. This study aimed to assess the challenges faced by women who used RMNCH services in Nigeria’s epicentre, their satisfaction with care received during the COVID-19 pandemic and the factors associated with their satisfaction. Methods This cross-sectional survey was conducted in Lagos, southwest Nigeria among 1,241 women of reproductive age who had just received RMNCH services at one of twenty-two health facilities across the primary, secondary and tertiary tiers of health care. The respondents were selected via multi-stage sampling and face to face exit interviews were conducted by trained interviewers. Client satisfaction was assessed across four sub-scales: Health care delivery, health facility, interpersonal aspects of care and access to services. Bivariate and multivariate analyses were used to assess the relationship between personal characteristics and client satisfaction. Results About 43.51% of respondents had at least one challenge in accessing RMNCH services since the COVID-19 outbreak. Close to a third (31.91%) could not access service because they could not leave their houses during the lockdown and 18.13% could not access service because there was no transportation. The mean clients’ satisfaction score among the respondents was 43.25 (SD: 6.28) out of a possible score of 57. Satisfaction scores for the interpersonal aspects of care were statistically significantly lower in the PHCs and general hospitals compared to teaching hospitals. Being over 30 years of age was significantly associated with an increased clients’ satisfaction score (ß = 1.80, 95%CI: 1.10-2.50). Conclusion The COVID-19 lockdown posed challenges to accessing RMNCH services for a significant proportion of women surveyed. Although overall satisfaction with care was fairly high, there is a need to provide tailored COVID-19 sensitive inter-personal care to clients at all levels of care. Copyright: This was a descriptive, cross-sectional survey conducted in Lagos, southwest Nigeria during the COVID-19 outbreak. Lagos State is divided into five administrative divisions namely Ikeja, Badagry, Ikorodu, Lagos and Epe. Health care delivery is structured along a three-tier system–tertiary, secondary and primary health care centres. The state has three public tertiary facilities which provide RMNCH services–Lagos University Teaching Hospital (LUTH), Lagos State University Teaching Hospital (LASUTH) and Federal Medical Centre, Ebute Metta. The state also has 26 secondary facilities (general hospitals) and 329 functional primary health care (PHC) facilities spread across the five administrative divisions, all of which provide RMNCH services i.e. integrated services for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood. The RMNCH services provided vary according to the level of care and include; 1) Clinical care: case management for sexually transmitted infections, post-abortion care, skilled obstetric care at birth and essential care for neonates, prevention of mother to child transmission of HIV, emergency obstetric care and immediate emergency care for newborn babies, case management of childhood and neonatal illness, care of children with HIV; 2) Outpatient and outreach services: family planning, prevention and management of sexually transmitted infections and HIV, antenatal care, postnatal care, childhood vaccination, nutrition and growth monitoring. The study population consisted of women of reproductive age (15–49 years) who had just received RMNCH services at one of the health facilities across the three tiers of care. Women were assessed to be eligible if they had accessed RMNCH services in the facility at least once during the COVID-19 outbreak in Lagos between 16th September 2020 and 12th October 2020. Those less than 18 years old were only included if they were emancipated, defined in this study as being married or living independently of parents. The minimum sample size of 400 was calculated using the Cochran’s formula and was based on 5% margin of error, 95% confidence interval, proportion (p) of 62.5% which represents overall satisfaction with MCH services in a hospital in southwest Nigeria [17], and 10% addition for non-response and recording errors. This sample size was tripled to account for design effect in using multiple sites making a sample size of 1,200 women. There was an equal allocation of the sample size to the three levels of care (i.e., 400 women per level of care). This was further allocated equally across the facilities for each level of care. Respondents were selected using a multi-stage sampling technique. At the first stage (facility level), the two teaching hospitals providing RMNCH services in Lagos State (LUTH and LASUTH) were purposively selected. Ten secondary facilities (two from each of the five administrative divisions) were selected by simple random sampling. Ten PHCs (two with the highest number of clients from each of the five administrative divisions) were selected purposively. At the participants level, consenting eligible participants were selected consecutively across all outpatient clinics providing RMNCH services until the sample size was attained. Exit interviews were conducted with eligible end-users of RMNCH at the selected facilities. A pretested, structured questionnaire was used by seven trained interviewers able to communicate in local languages to elicit information regarding socio-demography, challenges with accessing RMNCH services at the facilities and client satisfaction with these services since the COVID-19 epidemic in Lagos state. The client satisfaction items (S1 Questionnaire) were adapted from a validated tool to measure client-perceived quality of maternity services [18]. All questions were imputed in a form on the KoBoToolbox app (Harvard Humanitarian Initiative, Cambridge, Massachusetts, USA), which was the tool for data collection using smart phones. The instrument was pretested among 20 women of reproductive age in the Lagos environs and necessary adjustments were made to suit the local context. An item on access to credit was removed because it is not applicable to Lagos state health facilities. The research assistants observed strict COVID-19 safety rules such as use of face masks and encouragement of respondents to do same, hand hygiene and data collection in well-ventilated rooms and open spaces. The client satisfaction scales had 19 items in total and assessed satisfaction across four sub-scales: health care delivery, health facility, interpersonal aspects of care and access to services [18, 19]. The options and corresponding scores for these items were: not at all satisfied (score of 1), somewhat satisfied (score of 2) and completely satisfied (score of 3). Those that were not sure of the satisfaction of the specified item or for which the item did not apply were excluded from the analysis for that particular measure. Cronbach’s alpha was used to measure the internal consistency of the scale. The health care delivery sub-scale had 7 items with Cronbach alpha value of 0.72 and a possible range of scores between 1 to 21. The health facility sub-scale had 4 items with Cronbach alpha value of 0.73 and a possible range of 1 to 12. The sub-scale for interpersonal aspects of care had 6 items with a Cronbach alpha value of 0.80 and a possible range of 1 to 18. The access to services sub-scale had just 2 items which is less than the minimum of 3 items to calculate Cronbach alpha; it had a possible range of 1 to 6. Overall, the client satisfaction scale had a Cronbach alpha value of 0.86 with a range of 1 to 57. Univariate, bivariate and multivariate analyses were used to assess the relationship between the outcome variables and explanatory variables. At the univariate level, we estimated proportions for categorical variables and means and standard deviations for continuous variables. In bivariate analysis, we used one-way analysis of variance to determine statistically significant differences in mean scores across the three levels of care and the Bonferroni Procedure as a post-hoc test. Also, Student’s t-test was used to compare the mean client satisfaction scores across patients’ personal characteristics. This was followed by multiple linear regression to examine the association between personal characteristics and clients’ satisfaction. All independent variables in bivariate analyses with p-value <0.25 were included in the regression model and beta coefficient and 95% CI were computed for each predictor variable. The results were assessed to be significant at p-value <0.05. Data was analysed using STATA version SE15.1 (StataCorp, College Station, Texas, USA). Ethical approval for this study was obtained from the Health Research and Ethics Committee of Lagos University Teaching Hospital (LUTHHREC/EREV/0620/64). Social approval was obtained from the Lagos State Ministry of Health and permission to access the facilities was obtained from the Lagos State Health Services Commission and the Lagos State Primary Health Care Board. A waiver of signed consent was obtained from the ethics committee since the research presented minimal risk of harm to participants. Instead, verbal informed consent was obtained from all participants before any interview and documented by the research assistants on the data collection app. Their confidentiality was maintained by not using identifiers in the consent and data collection process.

AI Digest

Study Justification:

This study aimed to assess the challenges faced by women accessing reproductive, maternal, newborn, and child health (RMNCH) services in Nigeria during the COVID-19 pandemic. The presence of COVID-19 has disrupted health systems globally, and it is important to understand the specific challenges faced by women in accessing and receiving care during this time. By identifying these challenges, policymakers and healthcare providers can develop targeted interventions to improve access and satisfaction with RMNCH services.

Highlights:

– 43.51% of respondents experienced challenges in accessing RMNCH services since the COVID-19 outbreak.
– The main challenges reported were the inability to leave their houses during the lockdown (31.91%) and lack of transportation (18.13%).
– Overall satisfaction with care was fairly high, but satisfaction scores for interpersonal aspects of care were lower in primary health care centers and general hospitals compared to teaching hospitals.
– Being over 30 years of age was associated with increased satisfaction with care.

Recommendations:

– Tailored COVID-19 sensitive inter-personal care should be provided to clients at all levels of care to address the challenges faced during the pandemic.
– Efforts should be made to improve access to RMNCH services, particularly during lockdowns and periods of restricted movement.
– Training and capacity building programs should be implemented to enhance the quality of care provided in primary health care centers and general hospitals.
– Strategies should be developed to address transportation barriers, such as providing transportation services for women accessing RMNCH services.

Key Role Players:

– Ministry of Health: Responsible for policy development and coordination of healthcare services.
– Health Services Commission: Oversees the management and delivery of health services in Lagos State.
– Primary Health Care Board: Responsible for the management and coordination of primary health care services.
– Teaching Hospitals (LUTH, LASUTH, Federal Medical Centre, Ebute Metta): Provide tertiary-level RMNCH services.
– Secondary Facilities (General Hospitals): Provide secondary-level RMNCH services.
– Primary Health Care Facilities: Provide primary-level RMNCH services.

Cost Items for Planning Recommendations:

– Training and capacity building programs for healthcare providers.
– Transportation services for women accessing RMNCH services.
– Personal protective equipment for healthcare providers.
– Communication and awareness campaigns to educate women about available RMNCH services during the pandemic.
– Monitoring and evaluation activities to assess the effectiveness of interventions.
Please note that the cost items provided are general examples and may not reflect the actual cost or budget items specific to this study.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is described as a descriptive, cross-sectional survey, which provides valuable information about the challenges faced by women accessing reproductive, maternal, newborn, and child health (RMNCH) services during the COVID-19 pandemic in Nigeria. The sample size of 1,241 women is adequate for a cross-sectional study. The study also includes a multi-stage sampling technique, which enhances the representativeness of the findings. The use of face-to-face exit interviews conducted by trained interviewers adds to the reliability of the data. The study measures client satisfaction across four sub-scales, providing a comprehensive assessment of the quality of care received. However, there are some limitations to consider. The study was conducted in Lagos, southwest Nigeria, which may limit the generalizability of the findings to other regions. Additionally, the study relies on self-reported data, which may be subject to recall bias. To improve the evidence, future studies could consider using a longitudinal design to assess changes in access and satisfaction over time. It would also be beneficial to include a control group to compare the experiences of women accessing RMNCH services during the COVID-19 pandemic with those accessing services before the pandemic. Finally, incorporating qualitative methods, such as interviews or focus groups, could provide deeper insights into the challenges faced by women and potential strategies for improvement.

Resumo

This was a descriptive, cross-sectional survey conducted in Lagos, southwest Nigeria during the COVID-19 outbreak. Lagos State is divided into five administrative divisions namely Ikeja, Badagry, Ikorodu, Lagos and Epe. Health care delivery is structured along a three-tier system–tertiary, secondary and primary health care centres. The state has three public tertiary facilities which provide RMNCH services–Lagos University Teaching Hospital (LUTH), Lagos State University Teaching Hospital (LASUTH) and Federal Medical Centre, Ebute Metta. The state also has 26 secondary facilities (general hospitals) and 329 functional primary health care (PHC) facilities spread across the five administrative divisions, all of which provide RMNCH services i.e. integrated services for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood. The RMNCH services provided vary according to the level of care and include; 1) Clinical care: case management for sexually transmitted infections, post-abortion care, skilled obstetric care at birth and essential care for neonates, prevention of mother to child transmission of HIV, emergency obstetric care and immediate emergency care for newborn babies, case management of childhood and neonatal illness, care of children with HIV; 2) Outpatient and outreach services: family planning, prevention and management of sexually transmitted infections and HIV, antenatal care, postnatal care, childhood vaccination, nutrition and growth monitoring. The study population consisted of women of reproductive age (15–49 years) who had just received RMNCH services at one of the health facilities across the three tiers of care. Women were assessed to be eligible if they had accessed RMNCH services in the facility at least once during the COVID-19 outbreak in Lagos between 16th September 2020 and 12th October 2020. Those less than 18 years old were only included if they were emancipated, defined in this study as being married or living independently of parents. The minimum sample size of 400 was calculated using the Cochran’s formula and was based on 5% margin of error, 95% confidence interval, proportion (p) of 62.5% which represents overall satisfaction with MCH services in a hospital in southwest Nigeria [17], and 10% addition for non-response and recording errors. This sample size was tripled to account for design effect in using multiple sites making a sample size of 1,200 women. There was an equal allocation of the sample size to the three levels of care (i.e., 400 women per level of care). This was further allocated equally across the facilities for each level of care. Respondents were selected using a multi-stage sampling technique. At the first stage (facility level), the two teaching hospitals providing RMNCH services in Lagos State (LUTH and LASUTH) were purposively selected. Ten secondary facilities (two from each of the five administrative divisions) were selected by simple random sampling. Ten PHCs (two with the highest number of clients from each of the five administrative divisions) were selected purposively. At the participants level, consenting eligible participants were selected consecutively across all outpatient clinics providing RMNCH services until the sample size was attained. Exit interviews were conducted with eligible end-users of RMNCH at the selected facilities. A pretested, structured questionnaire was used by seven trained interviewers able to communicate in local languages to elicit information regarding socio-demography, challenges with accessing RMNCH services at the facilities and client satisfaction with these services since the COVID-19 epidemic in Lagos state. The client satisfaction items (S1 Questionnaire) were adapted from a validated tool to measure client-perceived quality of maternity services [18]. All questions were imputed in a form on the KoBoToolbox app (Harvard Humanitarian Initiative, Cambridge, Massachusetts, USA), which was the tool for data collection using smart phones. The instrument was pretested among 20 women of reproductive age in the Lagos environs and necessary adjustments were made to suit the local context. An item on access to credit was removed because it is not applicable to Lagos state health facilities. The research assistants observed strict COVID-19 safety rules such as use of face masks and encouragement of respondents to do same, hand hygiene and data collection in well-ventilated rooms and open spaces. The client satisfaction scales had 19 items in total and assessed satisfaction across four sub-scales: health care delivery, health facility, interpersonal aspects of care and access to services [18, 19]. The options and corresponding scores for these items were: not at all satisfied (score of 1), somewhat satisfied (score of 2) and completely satisfied (score of 3). Those that were not sure of the satisfaction of the specified item or for which the item did not apply were excluded from the analysis for that particular measure. Cronbach’s alpha was used to measure the internal consistency of the scale. The health care delivery sub-scale had 7 items with Cronbach alpha value of 0.72 and a possible range of scores between 1 to 21. The health facility sub-scale had 4 items with Cronbach alpha value of 0.73 and a possible range of 1 to 12. The sub-scale for interpersonal aspects of care had 6 items with a Cronbach alpha value of 0.80 and a possible range of 1 to 18. The access to services sub-scale had just 2 items which is less than the minimum of 3 items to calculate Cronbach alpha; it had a possible range of 1 to 6. Overall, the client satisfaction scale had a Cronbach alpha value of 0.86 with a range of 1 to 57. Univariate, bivariate and multivariate analyses were used to assess the relationship between the outcome variables and explanatory variables. At the univariate level, we estimated proportions for categorical variables and means and standard deviations for continuous variables. In bivariate analysis, we used one-way analysis of variance to determine statistically significant differences in mean scores across the three levels of care and the Bonferroni Procedure as a post-hoc test. Also, Student’s t-test was used to compare the mean client satisfaction scores across patients’ personal characteristics. This was followed by multiple linear regression to examine the association between personal characteristics and clients’ satisfaction. All independent variables in bivariate analyses with p-value <0.25 were included in the regression model and beta coefficient and 95% CI were computed for each predictor variable. The results were assessed to be significant at p-value <0.05. Data was analysed using STATA version SE15.1 (StataCorp, College Station, Texas, USA). Ethical approval for this study was obtained from the Health Research and Ethics Committee of Lagos University Teaching Hospital (LUTHHREC/EREV/0620/64). Social approval was obtained from the Lagos State Ministry of Health and permission to access the facilities was obtained from the Lagos State Health Services Commission and the Lagos State Primary Health Care Board. A waiver of signed consent was obtained from the ethics committee since the research presented minimal risk of harm to participants. Instead, verbal informed consent was obtained from all participants before any interview and documented by the research assistants on the data collection app. Their confidentiality was maintained by not using identifiers in the consent and data collection process.

Materiais

Inovações

Based on the information provided, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can allow pregnant women to consult with healthcare providers remotely, reducing the need for in-person visits and improving access to care, especially during situations like the COVID-19 pandemic.

2. Mobile clinics: Setting up mobile clinics that travel to remote or underserved areas can bring maternal health services closer to women who may have difficulty accessing traditional healthcare facilities.

3. Community health workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and pregnant women in rural or marginalized communities. These workers can provide education, support, and basic healthcare services.

4. Digital health platforms: Developing digital platforms or mobile applications that provide information, resources, and appointment scheduling for maternal health services can empower women to take control of their own healthcare and improve access to necessary services.

5. Transportation solutions: Addressing transportation challenges by providing affordable or subsidized transportation options for pregnant women can ensure they can reach healthcare facilities when needed.

6. Public-private partnerships: Collaborating with private sector organizations, such as ride-sharing companies or telecommunication providers, can leverage their resources and expertise to improve access to maternal health services.

7. Maternal health vouchers: Implementing voucher programs that provide financial assistance for maternal health services can help reduce financial barriers and increase access to quality care.

8. Maternal waiting homes: Establishing maternal waiting homes near healthcare facilities can provide temporary accommodation for pregnant women who live far away, ensuring they have a safe place to stay before and after delivery.

9. Health education campaigns: Conducting targeted health education campaigns to raise awareness about the importance of maternal health and available services can help overcome cultural and social barriers that may prevent women from seeking care.

10. Task-shifting: Training and empowering non-physician healthcare providers, such as nurses or midwives, to perform certain tasks traditionally done by doctors can help alleviate the shortage of skilled healthcare professionals and improve access to maternal health services.

It’s important to note that the specific context and needs of the community should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

Develop a mobile health (mHealth) application that provides information and resources for pregnant women and new mothers in Nigeria. The app should include features such as:

1. Access to accurate and up-to-date information on reproductive, maternal, newborn, and child health (RMNCH) services, including antenatal care, postnatal care, family planning, and childhood vaccination.

2. Reminders and notifications for important appointments and vaccinations, helping women stay on track with their healthcare needs.

3. A directory of healthcare facilities, including primary health care centers (PHCs), general hospitals, and tertiary hospitals, with information on their services, location, and contact details.

4. Real-time updates on the availability of services and any disruptions due to emergencies or lockdowns, ensuring that women can plan their visits accordingly.

5. Access to telemedicine services, allowing women to consult healthcare providers remotely for non-emergency concerns or follow-up appointments.

6. A feedback and rating system for women to share their experiences with different healthcare facilities, helping others make informed decisions and encouraging providers to improve the quality of care.

7. Educational resources on pregnancy, childbirth, breastfeeding, and newborn care, promoting healthy practices and empowering women to make informed decisions about their health.

8. Language options and user-friendly interface to cater to women from diverse backgrounds and literacy levels.

By developing and implementing this mHealth application, pregnant women and new mothers in Nigeria will have improved access to essential RMNCH services, reliable information, and support, even during challenging times like the COVID-19 pandemic. This innovation can help bridge the gap in accessing maternal health services and contribute to better health outcomes for women and their children.

AI Innovations Methodology

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

1. Telemedicine and virtual consultations: Implementing telemedicine services can allow pregnant women to receive medical advice and consultations remotely, reducing the need for physical visits to healthcare facilities.

2. Mobile health (mHealth) applications: Developing user-friendly mobile applications that provide information on prenatal care, nutrition, and appointment reminders can help women access essential maternal health services and stay informed about their pregnancy.

3. Community health workers: Expanding the role of community health workers can improve access to maternal health services, especially in remote areas. These workers can provide education, support, and referrals to pregnant women, ensuring they receive the care they need.

4. Transportation services: Establishing transportation services specifically for pregnant women can address the challenge of limited transportation during lockdowns or in areas with inadequate transportation infrastructure.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of prenatal visits, percentage of women receiving timely care, or reduction in maternal mortality rates.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including the number of prenatal visits, transportation availability, and satisfaction levels of women using RMNCH services.

3. Simulate the interventions: Use modeling techniques to simulate the implementation of the recommended interventions. This could involve creating scenarios that reflect the potential impact of each intervention on access to maternal health services.

4. Analyze the results: Evaluate the simulated outcomes of each intervention, comparing them to the baseline data. Assess the potential improvements in access to maternal health services, such as increased utilization rates, reduced barriers, and improved satisfaction levels.

5. Refine and iterate: Based on the analysis, refine the interventions and simulate again to assess their potential impact. Iterate this process until the most effective combination of interventions is identified.

6. Implement and monitor: Once the interventions are finalized, implement them in real-world settings. Continuously monitor and evaluate the impact of the interventions to ensure they are achieving the desired outcomes and make adjustments as needed.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions on improving access to maternal health services and make informed decisions about their implementation.

Autor

Dima Health

Statistics:

Citations: 22

Identifiers:

DOI: 10.1371/journal.pone.0251382

Research Areas:

Community Interventions, COVID, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Nigeria

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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