Effect of COVID-19 pandemic on provision of sexual and reproductive health services in primary health facilities in Nigeria: a cross-sectional study

Reproductive Health, Volume 18, No. 1, Year 2021

Interpretação

Background: Nigeria, like many other countries, has been severely affected by the COVID-19 pandemic. While efforts have been devoted to curtailing the disease, a major concern has been its potential effects on the delivery and utilization of reproductive health care services in the country. The objective of the study was to investigate the extent to which the COVID-19 pandemic and related lockdowns had affected the provision of essential reproductive, maternal, child, and adolescent health (RMCAH) services in primary health care facilities across the Nigerian States. Methods: This was a cross-sectional study of 307 primary health centres (PHCs) in 30 Local Government Areas in 10 States, representing the six geopolitical regions of the country. A semi-structured interviewer-administered questionnaire was used to obtain data on issues relating to access and provision of RMCAH services before, during and after COVID-19 lockdowns from the head nurses/midwives in the facilities. The questionnaire was entered into Open Data Kit mounted on smartphones. Data were analysed using frequency and percentage, summary statistics, and Kruskal–Wallis test. Results: Between 76 and 97% of the PHCS offered RMCAH services before the lockdown. Except in antenatal, delivery and adolescent care, there was a decline of between 2 and 6% in all the services during the lockdown and up to 10% decline after the lockdown with variation across and within States. During the lockdown. Full-service delivery was reported by 75.2% whereas 24.8% delivered partial services. There was a significant reduction in clients’ utilization of the services during the lockdown, and the difference between States before the pandemic, during, and after the lockdown. Reported difficulties during the lockdown included stock-out of drugs (25.7%), stock-out of contraceptives (25.1%), harassment by the law enforcement agents (76.9%), and transportation difficulties (55.8%). Only 2% of the PHCs reported the availability of gowns, 18% had gloves, 90.1% had hand sanitizers, and a temperature checker was available in 94.1%. Slightly above 10% identified clients with symptoms of COVID-19. Conclusions: The large proportion of PHCs who provided RMCAH services despite the lockdown demonstrates resilience. Considering the several difficulties reported, and the limited provision of primary protective equipment more effort by the government and non-governmental agencies is recommended to strengthen delivery of sexual and reproductive health in primary health centres in Nigeria during the pandemic. The study was part of a bigger intervention initiated by the UNFPA and implemented by three non-governmental organizations (NGOs): The Women’s Health and Action Research Centre (WHARC), Education as a Vaccine (EVA), and the Planned Parenthood Federation of Nigeria (PPFN). The three implementation partners (IPs) worked in partnership with three identified Civil Society Organizations (CSOs) per State to conduct the study. Overall, 30 CSOs worked with WHARC, EVA and the PPFN to conduct the study. The design was a cross-sectional descriptive study conducted in selected Primary Health Centres (PHCs) in two–three purposefully selected Local Government Areas (LGAs) in 10 States in Nigeria. The states were Lagos, Akwa Ibom, Kano, Kaduna, Gombe, Borno, Ogun, Enugu, Adamawa, and the Federal Capital Territory (FCT) (Abuja Municipal Area Council). The states were drawn from the six geopolitical zones or region of Nigeria (North Central, North East, North West, South East, South-South, and South West). A total of 32 PHCs were purposefully selected from the LGAs in each State, making a total of 320 health facilities. The head nurse/midwife (or Deputy) in each PHC was the respondent. The respondents were all female who had attained national training qualifications and registration requirements with the Nigerian Nursing and Midwifery Council. The exclusion criteria were non-functional, and inaccessible (due to security reasons) PHCs before and after the pandemic started. A total of 307 PHCs were successfully assessed (a non-response rate of 4.1%). The prevalence of COVID-19 cases informed the selection of States and LGAs. States with a relatively higher prevalence of COVID-19 cases were selected. With assistance from the Ministry of Health, and the State Primary Health Care Development Agency in each state, LGAs with high prevalence and the functional and accessible PHCs in the LGAs were identified and selected for the study. We ensured a mix of rural, semi-urban and urban LGAs. The study protocol was developed in WHARC and revised and finalised by all IPs. Thereafter, each CSO identified the respondents for health facilities in each State. The data collectors were trained by the IPs in the art of collecting quantitative survey data. The data were collected from November 1 to December 16, 2020, with a questionnaire that was programmed into the Open Data Kit (ODK) for interviewer-administered computer-assisted personal interviewing. The weekly records from each service was sighted and reviewed weekly. The questionnaire contained basic questions on the description of the health facility, maternal, child, adolescent health service delivery and utilization, and difficulties experienced before, during and after the COVID-19 pandemic lockdown. The COVID-19 lockdown took place in Nigeria in mid-March 2020 and was eased in September 2020. Thus, the period before the lockdown was identified as any time before March 15, 2020, while the lockdown period was from March 15 to the end of September 2020. The period after September 2020 when no lock-down occurred, and all schools, markets and Churches were re-opened to users was defined as the post lockdown period. Specific questions were asked on service delivery before, during and after the lockdowns. The specific services whose functionality were investigated were family planning, antenatal care, delivery (intrapartum) care, immunization services, and adolescent reproductive health services. The details of these services are as provided in the national guidelines for PHC system in Nigeria [21] The respondents were asked what reproductive, maternal, child, and adolescent and adolescent health (RMNCH) services they provided before the pandemic started, during the lockdown, and after the lockdown. The response was a multiple choice 8-item list which included family planning, antenatal, delivery, postnatal, child immunization, childcare, adolescent care, and others (to be specified). Response was also solicited on the closure of the facilities during the lockdown and whether services were offered fully or partially, the number of clients per week (records were sighted), difficulties in service delivery such as stock-outs and transportation, harassment by law enforcement agents (undue delay and questioning by the police or other law enforcement agents), the availability of personal protective equipment, and the identification and management of persons with suspected symptoms of COVID-19. The data were extracted from the ODK to SPSS PC + software for data cleaning and analysis. The descriptive results are presented as absolute numbers, percentage, mean and standard deviation, and range where appropriate. Further analysis to determine a statistically significant difference between States in the number of clients utilizing each service before the pandemic, during and after the lockdown was conducted. The distribution for each service was not normal and the Levene test of homogeneity of variances was also violated for each service. Thus, the non-parametric alternative of one-way between-groups analysis of variance (Kruskal–Wallis test) was used to determine whether there was a significant difference by State. The alpha was set at 0.05. The Ministries of Health in the ten States provided permission and ethical approval to undertake the study in the states. Each Ministry was approached differently and informed of the purpose of the study. The research teams then had meetings with responsive officers who reviewed the study protocol in detail and provided ethical approvals through their ethical review committees. The Local Government officers in charge of the PHCs also provided approval, while further consent was obtained from the lead officers in each PHCs. Only officials who accepted to complete the fully explained protocol were finally included in the study. They were assured of confidentiality of information they provide and also that their names would not feature in the protocol or anywhere in the study report.

AI Digest

Study Justification:

The study aimed to investigate the impact of the COVID-19 pandemic and related lockdowns on the provision of essential reproductive, maternal, child, and adolescent health (RMCAH) services in primary health care facilities in Nigeria. This was important because the pandemic and lockdown measures could potentially disrupt access to these critical health services, leading to negative health outcomes for women, children, and adolescents.

Study Highlights:

– Between 76% and 97% of primary health centers (PHCs) offered RMCAH services before the lockdown.
– During the lockdown, there was a decline of 2% to 6% in all services, except for antenatal, delivery, and adolescent care.
– After the lockdown, there was a further decline of up to 10% in service utilization, with variations across and within states.
– Difficulties reported during the lockdown included stock-outs of drugs and contraceptives, harassment by law enforcement agents, and transportation difficulties.
– Only a small percentage of PHCs had adequate personal protective equipment.
– Efforts by the government and non-governmental agencies are recommended to strengthen the delivery of sexual and reproductive health services in primary health centers during the pandemic.

Study Recommendations:

– Increase efforts to strengthen the delivery of sexual and reproductive health services in primary health centers during the COVID-19 pandemic.
– Address stock-outs of drugs and contraceptives to ensure uninterrupted service provision.
– Provide adequate personal protective equipment to protect healthcare workers and clients.
– Address transportation difficulties to improve access to health facilities.
– Address harassment by law enforcement agents to ensure smooth service delivery.

Key Role Players:

– Ministry of Health: Provides overall guidance and support for implementing the recommendations.
– Primary Health Care Development Agency: Coordinates and supports the implementation of the recommendations at the state level.
– Women’s Health and Action Research Centre (WHARC): Provides technical expertise and support in implementing the recommendations.
– Education as a Vaccine (EVA): Supports the implementation of the recommendations, particularly in the area of adolescent reproductive health.
– Planned Parenthood Federation of Nigeria (PPFN): Supports the implementation of the recommendations, particularly in the area of family planning.
– Civil Society Organizations (CSOs): Work in partnership with the implementation partners to conduct the study and can continue to play a role in advocating for the implementation of the recommendations.

Cost Items for Planning Recommendations:

– Procurement of drugs and contraceptives to address stock-outs.
– Procurement of personal protective equipment for healthcare workers.
– Transportation support to improve access to health facilities.
– Training and capacity building for healthcare workers on COVID-19 prevention and service delivery.
– Awareness campaigns and community engagement activities to address stigma and misinformation.
– Monitoring and evaluation activities to track the implementation and impact of the recommendations.
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on various factors such as the scale of implementation and specific context.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study conducted in 307 primary health centers in Nigeria. The study used a semi-structured questionnaire to collect data on the provision of reproductive, maternal, child, and adolescent health services before, during, and after the COVID-19 lockdowns. The data were analyzed using frequency and percentage, summary statistics, and the Kruskal-Wallis test. The study provides valuable insights into the impact of the pandemic on the delivery and utilization of these services. However, there are a few actionable steps to improve the evidence. Firstly, the abstract could provide more details on the sampling method and representativeness of the sample. Secondly, it would be helpful to include information on the response rate and any potential biases in the data collection process. Lastly, the abstract could mention the limitations of the study and potential sources of bias, such as self-reporting by the head nurses/midwives. These improvements would enhance the transparency and reliability of the evidence.

Resumo

The study was part of a bigger intervention initiated by the UNFPA and implemented by three non-governmental organizations (NGOs): The Women’s Health and Action Research Centre (WHARC), Education as a Vaccine (EVA), and the Planned Parenthood Federation of Nigeria (PPFN). The three implementation partners (IPs) worked in partnership with three identified Civil Society Organizations (CSOs) per State to conduct the study. Overall, 30 CSOs worked with WHARC, EVA and the PPFN to conduct the study. The design was a cross-sectional descriptive study conducted in selected Primary Health Centres (PHCs) in two–three purposefully selected Local Government Areas (LGAs) in 10 States in Nigeria. The states were Lagos, Akwa Ibom, Kano, Kaduna, Gombe, Borno, Ogun, Enugu, Adamawa, and the Federal Capital Territory (FCT) (Abuja Municipal Area Council). The states were drawn from the six geopolitical zones or region of Nigeria (North Central, North East, North West, South East, South-South, and South West). A total of 32 PHCs were purposefully selected from the LGAs in each State, making a total of 320 health facilities. The head nurse/midwife (or Deputy) in each PHC was the respondent. The respondents were all female who had attained national training qualifications and registration requirements with the Nigerian Nursing and Midwifery Council. The exclusion criteria were non-functional, and inaccessible (due to security reasons) PHCs before and after the pandemic started. A total of 307 PHCs were successfully assessed (a non-response rate of 4.1%). The prevalence of COVID-19 cases informed the selection of States and LGAs. States with a relatively higher prevalence of COVID-19 cases were selected. With assistance from the Ministry of Health, and the State Primary Health Care Development Agency in each state, LGAs with high prevalence and the functional and accessible PHCs in the LGAs were identified and selected for the study. We ensured a mix of rural, semi-urban and urban LGAs. The study protocol was developed in WHARC and revised and finalised by all IPs. Thereafter, each CSO identified the respondents for health facilities in each State. The data collectors were trained by the IPs in the art of collecting quantitative survey data. The data were collected from November 1 to December 16, 2020, with a questionnaire that was programmed into the Open Data Kit (ODK) for interviewer-administered computer-assisted personal interviewing. The weekly records from each service was sighted and reviewed weekly. The questionnaire contained basic questions on the description of the health facility, maternal, child, adolescent health service delivery and utilization, and difficulties experienced before, during and after the COVID-19 pandemic lockdown. The COVID-19 lockdown took place in Nigeria in mid-March 2020 and was eased in September 2020. Thus, the period before the lockdown was identified as any time before March 15, 2020, while the lockdown period was from March 15 to the end of September 2020. The period after September 2020 when no lock-down occurred, and all schools, markets and Churches were re-opened to users was defined as the post lockdown period. Specific questions were asked on service delivery before, during and after the lockdowns. The specific services whose functionality were investigated were family planning, antenatal care, delivery (intrapartum) care, immunization services, and adolescent reproductive health services. The details of these services are as provided in the national guidelines for PHC system in Nigeria [21] The respondents were asked what reproductive, maternal, child, and adolescent and adolescent health (RMNCH) services they provided before the pandemic started, during the lockdown, and after the lockdown. The response was a multiple choice 8-item list which included family planning, antenatal, delivery, postnatal, child immunization, childcare, adolescent care, and others (to be specified). Response was also solicited on the closure of the facilities during the lockdown and whether services were offered fully or partially, the number of clients per week (records were sighted), difficulties in service delivery such as stock-outs and transportation, harassment by law enforcement agents (undue delay and questioning by the police or other law enforcement agents), the availability of personal protective equipment, and the identification and management of persons with suspected symptoms of COVID-19. The data were extracted from the ODK to SPSS PC + software for data cleaning and analysis. The descriptive results are presented as absolute numbers, percentage, mean and standard deviation, and range where appropriate. Further analysis to determine a statistically significant difference between States in the number of clients utilizing each service before the pandemic, during and after the lockdown was conducted. The distribution for each service was not normal and the Levene test of homogeneity of variances was also violated for each service. Thus, the non-parametric alternative of one-way between-groups analysis of variance (Kruskal–Wallis test) was used to determine whether there was a significant difference by State. The alpha was set at 0.05. The Ministries of Health in the ten States provided permission and ethical approval to undertake the study in the states. Each Ministry was approached differently and informed of the purpose of the study. The research teams then had meetings with responsive officers who reviewed the study protocol in detail and provided ethical approvals through their ethical review committees. The Local Government officers in charge of the PHCs also provided approval, while further consent was obtained from the lead officers in each PHCs. Only officials who accepted to complete the fully explained protocol were finally included in the study. They were assured of confidentiality of information they provide and also that their names would not feature in the protocol or anywhere in the study report.

Materiais

https://efashare.b-cdn.net/materials/91a9e35fa5cf0a7a90a1e0a5e7b806a909b6ae2e021314fc8fa552cb6e098d98/12978_2021_1217_MOESM1_ESM.docx

Inovações

Based on the provided information, here are some potential innovations that could be used to 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 health (mHealth) applications: Developing mobile applications that provide pregnant women with access to educational resources, appointment reminders, and personalized health information can help improve their knowledge and engagement in their own maternal health care.

3. Community health workers: Training and deploying community health workers to provide essential maternal health services at the community level can help bridge the gap between health facilities and pregnant women in remote or underserved areas.

4. Supply chain management systems: Implementing efficient supply chain management systems can help ensure the availability of essential drugs, contraceptives, and personal protective equipment in primary health centers, reducing stock-outs and improving the quality of care.

5. Public-private partnerships: Collaborating with private sector organizations can help leverage their resources and expertise to improve access to maternal health services, such as providing transportation support for pregnant women in need.

6. Health financing mechanisms: Exploring innovative health financing mechanisms, such as community-based health insurance or conditional cash transfer programs, can help reduce financial barriers and increase access to maternal health services for vulnerable populations.

7. Data-driven decision-making: Utilizing data analytics and digital health platforms to collect and analyze real-time data on maternal health service utilization can help identify gaps and inform targeted interventions to improve access and quality of care.

It’s important to note that the specific context and needs of Nigeria should be taken into consideration 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:

Implement a mobile health (mHealth) platform to provide remote access to reproductive, maternal, child, and adolescent health (RMCAH) services in primary health care facilities across Nigeria. This mHealth platform can be developed as a smartphone application or a web-based platform that allows pregnant women and new mothers to access essential RMCAH services from the comfort of their homes.

Key features of the mHealth platform can include:

1. Teleconsultations: Enable pregnant women and new mothers to have virtual consultations with healthcare providers, where they can discuss their concerns, receive medical advice, and get prescriptions if needed.

2. Appointment scheduling: Allow users to book appointments for antenatal care, postnatal care, and other RMCAH services through the platform. This can help reduce waiting times and ensure timely access to healthcare.

3. Health education and information: Provide educational resources and information on pregnancy, childbirth, breastfeeding, infant care, and family planning. This can empower women with knowledge to make informed decisions about their health and the health of their children.

4. Remote monitoring: Integrate remote monitoring devices, such as wearable devices or home-based monitoring kits, to collect vital health data (e.g., blood pressure, weight, fetal movements) and share it with healthcare providers. This can enable early detection of complications and timely interventions.

5. Medication reminders: Send automated reminders to women to take their medications, such as prenatal vitamins or contraceptives, to improve adherence and continuity of care.

6. Referral system: Facilitate seamless referrals between primary health care facilities and higher-level healthcare facilities for specialized care when needed. This can ensure continuity of care and timely access to appropriate services.

7. Feedback and support: Provide a feedback mechanism for users to share their experiences, report any issues or concerns, and receive support from healthcare providers. This can help improve the quality of services and address any barriers or challenges faced by women.

By implementing this mHealth platform, pregnant women and new mothers in Nigeria can overcome barriers to accessing RMCAH services, such as transportation difficulties, stock-outs of drugs and contraceptives, and harassment by law enforcement agents. It can also help bridge the gap in healthcare services caused by the COVID-19 pandemic and improve overall maternal health outcomes in the country.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations for improving access to maternal health:

1. Strengthen the supply chain: Address the reported stock-out of drugs and contraceptives by improving the supply chain management system. This can include regular monitoring of stock levels, forecasting demand, and ensuring timely procurement and distribution of essential maternal health supplies.

2. Enhance transportation services: Address transportation difficulties by improving access to reliable and affordable transportation options for pregnant women. This can involve partnering with transportation providers, implementing transportation subsidies, or establishing community-based transportation services specifically for maternal health purposes.

3. Increase availability of personal protective equipment (PPE): Address the limited provision of primary protective equipment by ensuring an adequate supply of PPE in primary health centers. This can include regular procurement and distribution of PPE, training healthcare workers on proper PPE usage, and implementing infection prevention and control measures.

4. Strengthen community engagement: Engage with communities to raise awareness about the importance of maternal health services and address any misconceptions or fears related to seeking care during the COVID-19 pandemic. This can involve community outreach programs, health education campaigns, and involving community leaders and influencers in promoting maternal health services.

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 reflect access to maternal health services, such as the number of antenatal care visits, facility-based deliveries, or contraceptive uptake.

2. Collect baseline data: Gather data on the current status of these indicators before implementing the recommendations. This can be done through surveys, interviews, or analysis of existing data sources.

3. Implement the recommendations: Introduce the recommended interventions, such as strengthening the supply chain, enhancing transportation services, increasing availability of PPE, and strengthening community engagement.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can involve regular data collection from health facilities, surveys of pregnant women and healthcare providers, or analysis of routine health information systems.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on the selected indicators. This can involve comparing the post-intervention data with the baseline data to determine any changes or improvements.

6. Evaluate and adjust: Evaluate the effectiveness of the interventions and make any necessary adjustments or refinements. This can involve identifying any challenges or barriers to implementation and modifying the interventions accordingly.

By following this methodology, it would be possible to simulate the impact of the recommended interventions on improving access to maternal health services and assess their effectiveness in the context of the COVID-19 pandemic in Nigeria.

Autor

Dima Health

Statistics:

Citations: 16

Identifiers:

DOI: 10.1186/s12978-021-01217-5

Research Areas:

Community Interventions, COVID, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury, Workforce

Study Countries:

Nigeria

Study Design:

Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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