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

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Study Justification:
– The study aimed to explore the barriers and facilitators of access to maternal, newborn, and child health (MNCH) services during the first wave of the COVID-19 pandemic in Nigeria.
– The study was conducted to understand the extent, directions, and contextual factors affecting healthcare service delivery in Nigeria during the pandemic.
Study Highlights:
– Barriers to accessing MNCH services during the first wave of the COVID-19 pandemic in Nigeria included fear of contracting COVID-19 at health facilities, transportation difficulties, stigmatization of sick persons, lack of personal protective equipment (PPE) and medical commodities, long waiting times at hospitals, shortage of manpower, lack of preparedness by health workers, and prioritization of essential services.
– Enablers to access included the COVID-19 non-pharmacological measures implemented at health facilities, community sensitization on healthcare access during the pandemic, and alternative strategies for administering immunization services at clinics.
– Access to MNCH services was negatively affected by lockdown measures during the first wave of the pandemic, which restricted movements and hindered patients and healthcare providers from reaching hospitals. Financial constraints also affected patients’ ability to pay for healthcare services.
– The study recommended that alternative measures be instituted to halt the spread of diseases instead of lockdowns, ensuring unhindered access to MNCH services during future pandemics. Recommendations included immediate sensitization of the general public on modes of transmission of emergent infectious diseases, training of health workers on emergency preparedness, and alternative service delivery models.
Key Role Players:
– Government officials and policymakers
– Healthcare providers
– Community leaders and influencers
– Non-governmental organizations (NGOs) working in healthcare
– Researchers and academics
Cost Items for Planning Recommendations:
– Public awareness campaigns and sensitization materials
– Training programs for health workers on emergency preparedness
– Development and implementation of alternative service delivery models
– Procurement and distribution of personal protective equipment (PPE) and medical commodities
– Infrastructure improvements to reduce waiting times at hospitals
– Recruitment and training of additional healthcare personnel
– Research and evaluation of the effectiveness of implemented measures

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it provides a clear description of the study design, methods, and findings. The study utilized a qualitative approach to explore the barriers and facilitators of access to maternal, newborn, and child health services during the first wave of the COVID-19 pandemic in Nigeria. In-depth interviews were conducted among different stakeholder groups in 18 public health facilities. The qualitative data were analyzed using thematic analysis. The abstract provides a comprehensive overview of the study’s objectives, methods, and key findings. However, to improve the evidence, the abstract could include more specific details about the sample size and characteristics of the study participants, as well as the limitations of the study. Additionally, it would be helpful to include information about the generalizability of the findings and any implications for policy or practice.

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.

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

1. Telemedicine: Implementing telemedicine services can allow pregnant women to receive virtual consultations and check-ups from the comfort of their homes, reducing the need for in-person visits and minimizing the risk of exposure to COVID-19.

2. Mobile clinics: Establishing mobile clinics that can travel to remote areas or communities with limited access to healthcare facilities can ensure that pregnant women receive essential prenatal care and services closer to their homes.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and support within their communities can help bridge the gap in access to healthcare facilities, especially in areas with limited resources.

4. Digital health tools: Developing and promoting the use of mobile applications or SMS-based platforms that provide information, reminders, and guidance on prenatal care, nutrition, and maternal health can empower pregnant women to take control of their own health and make informed decisions.

5. Public-private partnerships: Collaborating with private healthcare providers and organizations to expand access to maternal health services can help alleviate the strain on public healthcare facilities and ensure that pregnant women have more options for care.

6. Supply chain management: Improving the supply chain management of essential maternal health commodities, such as personal protective equipment (PPE), medications, and medical equipment, can ensure that healthcare facilities have an adequate and continuous supply, reducing barriers to access.

7. Health education and awareness campaigns: Conducting targeted health education and awareness campaigns to address misconceptions, fears, and stigmatization related to COVID-19 and maternal health can help alleviate concerns and encourage pregnant women to seek necessary care.

8. Strengthening emergency preparedness: Investing in emergency preparedness training for healthcare workers and developing alternative service delivery models can help healthcare facilities respond effectively during future pandemics or crises, ensuring uninterrupted access to maternal health services.

These innovations can help overcome the barriers identified in the study and improve access to maternal health services during and beyond the COVID-19 pandemic.
AI Innovations Description
Based on the findings of the qualitative study, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Alternative service delivery models: The study identified that lockdowns and movement restrictions during the COVID-19 pandemic negatively affected access to maternal and child health services. To address this, governments and healthcare systems can develop and implement alternative service delivery models that ensure unhindered access to maternal health services during future pandemics or similar situations. This could include telemedicine consultations, home-based care, mobile clinics, or community-based outreach programs. By leveraging technology and innovative approaches, pregnant women can receive necessary care and support without the need for physical visits to healthcare facilities.

Implementing such alternative service delivery models would require collaboration between healthcare providers, policymakers, and technology experts. It would also involve educating and sensitizing the general public about these alternative options and ensuring that healthcare workers are trained and equipped to provide care remotely.

By adopting innovative approaches to service delivery, access to maternal health services can be improved, even during challenging circumstances like a pandemic. This would help ensure that pregnant women receive the care they need, reducing maternal and neonatal mortality rates and improving overall maternal health outcomes.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening transportation systems: Addressing transportation difficulties can improve access to maternal health services. This can be achieved by implementing transportation programs or initiatives that provide reliable and affordable transportation options for pregnant women to reach healthcare facilities.

2. Ensuring availability of personal protective equipment (PPE) and medical commodities: Lack of PPE and medical commodities can hinder access to maternal health services. It is important to ensure an adequate supply of PPE and essential medical supplies in healthcare facilities to protect both healthcare providers and patients.

3. Reducing waiting times at hospitals: Long waiting times can discourage pregnant women from seeking maternal health services. Implementing strategies to reduce waiting times, such as optimizing appointment scheduling systems or increasing healthcare staff, can improve access and utilization of maternal health services.

4. Strengthening healthcare workforce: Shortage of manpower can limit access to maternal health services. Investing in training and recruitment of healthcare professionals, particularly in underserved areas, can help address this issue and ensure adequate staffing in healthcare facilities.

5. Community sensitization and education: Conducting community sensitization programs to raise awareness about the importance of maternal health services and debunking myths or misconceptions can encourage pregnant women to seek care. Providing education on the safety measures implemented in healthcare facilities during pandemics can also help alleviate fears of contracting infections.

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 specific indicators that measure access to maternal health services, such as the number of pregnant women accessing antenatal care, the number of deliveries attended by skilled birth attendants, or the reduction in maternal mortality rates.

2. Collect baseline data: Gather data on the current status of access to maternal health services, including the identified indicators. This can be done through surveys, interviews, or existing data sources.

3. Introduce the recommendations: Implement the recommended interventions or strategies in selected healthcare facilities or communities.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on the identified indicators. This can involve tracking the number of pregnant women utilizing services, conducting surveys or interviews to assess changes in perceptions and experiences, and documenting any challenges or successes encountered during implementation.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on improving access to maternal health services. This can involve comparing the baseline data with the post-implementation data to identify any changes or improvements.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health services. Identify any gaps or areas for further improvement and make recommendations for future interventions.

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

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