Gender discrimination as a barrier to high-quality maternal and newborn health care in Nigeria: findings from a cross-sectional quality of care assessment

BMC health services research, Volume 21, No. 1, Year 2021

Ukuhunyushwa

BACKGROUND: Poor reproductive, maternal, newborn, child, and adolescent health outcomes in Nigeria can be attributed to several factors, not limited to low health service coverage, a lack of quality care, and gender inequity. Providers’ gender-discriminatory attitudes, and men’s limited positive involvement correlate with poor utilization and quality of services. We conducted a study at the beginning of a large family planning (FP) and maternal, newborn, child, and adolescent health program in Kogi and Ebonyi States of Nigeria to assess whether or not gender plays a role in access to, use of, and delivery of health services. METHODS: We conducted a cross-sectional, observational, baseline quality of care assessment from April-July 2016 to inform a maternal and newborn health project in health facilities in Ebonyi and Kogi States. We observed 435 antenatal care consultations and 47 births, and interviewed 138 providers about their knowledge, training, experiences, working conditions, gender-sensitive and respectful care, and workplace gender dynamics. The United States Agency for International Development’s Gender Analysis Framework was used to analyze findings. RESULTS: Sixty percent of providers disagreed that a woman could choose a family planning method without a male partner’s involvement, and 23.2% of providers disagreed that unmarried clients should use family planning. Ninety-eight percent believed men should participate in health services, yet only 10% encouraged women to bring their partners. Harmful practices were observed in 59.6% of deliveries and disrespectful or abusive practices were observed in 34.0%. No providers offered clients information, services, or referrals for gender-based violence. Sixty-seven percent reported observing or hearing of an incident of violence against clients, and 7.9% of providers experienced violence in the workplace themselves. Over 78% of providers received no training on gender, gender-based violence, or human rights in the past 3 years. CONCLUSION: Addressing gender inequalities that limit women’s access, choice, agency, and autonomy in health services as a quality of care issue is critical to reducing poor health outcomes in Nigeria. Inherent gender discrimination in health service delivery reinforces the critical need for gender analysis, gender responsive approaches, values clarification, and capacity building for service providers. The baseline quality of care assessment was a cross-sectional, health facility-based study which examined service providers’ knowledge, skills, and gender-related beliefs, practices, and policies with respect to ANC services, labor and vaginal deliveries, and FP services. Study instruments included the following: ANC Observation Checklist, L&D Observation Checklist, FP Consult Observation Checklist, and a Maternal and Newborn Health Service Provider Interview Guide and Knowledge Test for providers who offered ANC and L&D services. Clinical observations of client-provider interactions were conducted by trained, practicing clinicians who directly observed care in real-time while using structured, standardized observation checklists. The checklists were developed and used by USAID’s Maternal and Child Health Integrated program, based on WHO-recommended evidence-based practices for ANC and L&D care [47]. The structured provider interview and knowledge test was a verbally-administered, quantitative tool (vs. a self-administered survey) that primarily included close-ended questions but also a few open-ended questions on the following topics: provider background charateristics and work environment, knowledge of evidence-based maternal and newborn health interventions, experience with violent and disrespectful treatment, and gender-specific atttitudes and beliefs that can affect client care [24]. The ANC checklist and provider included questions from the Service Provision Assessment, which has been widely used in low-and middle-income countries [48]. Samples were drawn from different units of the health facilities, including the maternity, antenatal, and FP units, with clustering of data by facility. A total of 40 health facilities targeted to receive quality improvement interventions in the first phase of MCSP implementation were purposively selected from a larger list of 120 health facilities in Kogi and Ebonyi States that were identified in consultation with the State Ministries of Health to receive support from MCSP. The study was powered based on the number ANC consultations to be directly observed. For observations of labor and delivery care, the plan was to observe all deliveries during the days of the study team’s visit because of the low caseload of deliveries in most of the facilities. Based on an assumption of 220 working days per year, ANC data extracted from registers of the selected health facilities indicated a combined average of 197 and 170 ANC visits per day in facilities in Ebonyi and Kogi, respectively. The desired sample size of ANC consultations to be observed was based on cluster sampling calculations (assuming health workers and clients are clustered within facilities) with a median design effect of 1.5 to allow + 12% precision in quality of care indicator estimates. The assumed prevalence for the quality of care indicators of interest was set at 50% to generate the most conservative sample size, with approximately 200 ANC consultations planned to be observed in each state. Target sample sizes were distributed across facility types based on identified ANC caseloads—proportional to size. Since more services took place at the tertiary level, the protocol planned for the observation of 20 ANC consultations in the tertiary facility, 12 consultations in each of the general and mission hospitals, and 5 consultations in each of the primary health centers and private clinics. Current national standards require that a minimum of four service providers work in the maternity unit of a facility to operate a shift-duty system. Therefore, based on an estimated minimum population of 160 eligible service providers (4 providers in each of the 40 health facilities), a 5% margin of error, and a 95% confidence interval, we planned to interview 136 ANC and labor and delivery providers. Twenty-two obstetricians, pediatricians, medical officers, nurses, and midwives were selected as data collectors for all the study tools based on their active clinical practice and data collection experience. All data collectors received 2 weeks of training that included a briefing on the background and rationale of the study, an overview of the study instruments and informed consent process, and orientation on all data collection tools, including gender-related aspects of the observational and interview tools and technical instructions for using CommCare technology, the mobile software used for data collection. Data collectors were trained on gender terms and to review records for missing or inconsistent answers before submission. Data collectors practiced using the study instruments in the classroom with colleagues during role plays and clinical simulations using anatomic models and inter-rater reliability of the observers’ scores was tested. Field tests using the tools were conducted over 2 days in five health facilities in Kogi States, and feedback was used to revise the tools and reword questions as necessary. Data collectors worked in teams whose staffing was based on the number of observations to be made and classifications of the health facilities. Data collection lasted 1–2 days in primary health centers and 2–4 days in larger secondary and tertiary health facilities. Repeat visits were made to complete the target number of ANC observations if needed; repeat visits were required more frequently in tertiary health facilities and general hospitals. Supervisors visited data collection teams to provide ongoing quality control. Data were collected in Kogi and Ebonyi States from 1 April through 30 June 2016 and entered directly on android-enabled tablet PCs using custom-created data entry programs developed with the password-protected CommCare software package. Technical and information technology staff monitored data sent to the CommCare HQ online site and verified data completeness and accuracy. Data were exported from CommCare to Excel before being converted to SPSS for cleaning and analysis. Data analyses performed included percent distributions, counts, means, medians and cross-tabulations. Responses to open-ended questions from the provider interview were collated and summarized by theme. Results for Kogi and Ebonyi States were analyzed separately due to significant sociocultural and normative differences in gender and health practices. For example, 74.2% of women in Ebonyi State have undergone female genital mutilation compared to 1.7% of women in Kogi State [1]. Descriptive gender analysis was used to answer the gender assessment questions of the quality of care findings. Gender analysis emphasizes the importance of examining not only supply-side issues in health service provision, but also demand-side issues and the interrelation of the two [42]. Gender analysis can reveal the complex interplay of gender inequality and other inequities that constitute barriers or facilitators for access to health services and provider-client interactions. It can also provide baseline information about providers’ knowledge, attitudes, and practices around gender during RMNCAH service delivery and uncovered gender-related barriers that hinder the provision of quality, respectful, and equally accessible health care. A descriptive analysis of gender-specific quality of care findings was conducted using USAID’s Gender Analysis Framework (Fig. 1) [44, 46] to examine gender-based constraints and opportunities in four domains: (1) Practices, roles, and participation; (2) Beliefs and perceptions; (3) Access to assets; and (4) Institutions, laws, and policies: Gender analysis framework

I-AI Digest

Study Justification:

The study aimed to investigate the role of gender discrimination in access to and delivery of maternal and newborn health care services in Nigeria. This was important because poor health outcomes in Nigeria are influenced by factors such as low health service coverage, lack of quality care, and gender inequity. By understanding the impact of gender discrimination on health services, the study aimed to provide evidence for addressing gender inequalities and improving health outcomes.

Highlights:

– The study found that a significant percentage of health care providers held gender-discriminatory attitudes, such as believing that women cannot choose family planning methods without their male partner’s involvement.
– Harmful practices were observed in a majority of deliveries, and disrespectful or abusive practices were observed in a significant proportion of cases.
– Providers reported a lack of training on gender, gender-based violence, and human rights, indicating a need for capacity building in these areas.
– The study highlighted the critical need for gender analysis, gender-responsive approaches, values clarification, and capacity building for service providers to address gender inequalities in health service delivery.

Recommendations:

– Address gender inequalities as a quality of care issue to improve health outcomes in Nigeria.
– Provide training on gender, gender-based violence, and human rights for health care providers.
– Promote gender-responsive approaches in health service delivery.
– Encourage men’s positive involvement in health services and support women in bringing their partners.
– Develop and implement policies and guidelines to prevent and address gender-based violence in health care settings.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation.
– Health Care Providers: Need to be trained on gender, gender-based violence, and human rights.
– Non-Governmental Organizations (NGOs): Can provide support in capacity building and implementation of gender-responsive approaches.
– Community Leaders: Play a role in promoting gender equality and addressing harmful practices.

Cost Items for Planning Recommendations:

– Training Programs: Budget for developing and delivering training on gender, gender-based violence, and human rights for health care providers.
– Capacity Building: Allocate funds for capacity building activities, including workshops, seminars, and mentoring programs.
– Policy Development: Consider the cost of developing and implementing policies and guidelines to address gender-based violence and promote gender-responsive approaches.
– Awareness Campaigns: Set aside a budget for raising awareness among the community about gender equality and the importance of men’s positive involvement in health services.

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a cross-sectional quality of care assessment conducted in health facilities in Nigeria. The study used structured observation checklists and interviews with providers to gather data. The findings highlight gender discrimination in health service delivery and its impact on access to and quality of care. To improve the evidence, the study could have included a larger sample size and conducted a longitudinal study to assess changes over time. Additionally, incorporating qualitative methods such as focus group discussions or in-depth interviews with women accessing the services could provide further insights into their experiences and perspectives.

Abstract

The baseline quality of care assessment was a cross-sectional, health facility-based study which examined service providers’ knowledge, skills, and gender-related beliefs, practices, and policies with respect to ANC services, labor and vaginal deliveries, and FP services. Study instruments included the following: ANC Observation Checklist, L&D Observation Checklist, FP Consult Observation Checklist, and a Maternal and Newborn Health Service Provider Interview Guide and Knowledge Test for providers who offered ANC and L&D services. Clinical observations of client-provider interactions were conducted by trained, practicing clinicians who directly observed care in real-time while using structured, standardized observation checklists. The checklists were developed and used by USAID’s Maternal and Child Health Integrated program, based on WHO-recommended evidence-based practices for ANC and L&D care [47]. The structured provider interview and knowledge test was a verbally-administered, quantitative tool (vs. a self-administered survey) that primarily included close-ended questions but also a few open-ended questions on the following topics: provider background charateristics and work environment, knowledge of evidence-based maternal and newborn health interventions, experience with violent and disrespectful treatment, and gender-specific atttitudes and beliefs that can affect client care [24]. The ANC checklist and provider included questions from the Service Provision Assessment, which has been widely used in low-and middle-income countries [48]. Samples were drawn from different units of the health facilities, including the maternity, antenatal, and FP units, with clustering of data by facility. A total of 40 health facilities targeted to receive quality improvement interventions in the first phase of MCSP implementation were purposively selected from a larger list of 120 health facilities in Kogi and Ebonyi States that were identified in consultation with the State Ministries of Health to receive support from MCSP. The study was powered based on the number ANC consultations to be directly observed. For observations of labor and delivery care, the plan was to observe all deliveries during the days of the study team’s visit because of the low caseload of deliveries in most of the facilities. Based on an assumption of 220 working days per year, ANC data extracted from registers of the selected health facilities indicated a combined average of 197 and 170 ANC visits per day in facilities in Ebonyi and Kogi, respectively. The desired sample size of ANC consultations to be observed was based on cluster sampling calculations (assuming health workers and clients are clustered within facilities) with a median design effect of 1.5 to allow + 12% precision in quality of care indicator estimates. The assumed prevalence for the quality of care indicators of interest was set at 50% to generate the most conservative sample size, with approximately 200 ANC consultations planned to be observed in each state. Target sample sizes were distributed across facility types based on identified ANC caseloads—proportional to size. Since more services took place at the tertiary level, the protocol planned for the observation of 20 ANC consultations in the tertiary facility, 12 consultations in each of the general and mission hospitals, and 5 consultations in each of the primary health centers and private clinics. Current national standards require that a minimum of four service providers work in the maternity unit of a facility to operate a shift-duty system. Therefore, based on an estimated minimum population of 160 eligible service providers (4 providers in each of the 40 health facilities), a 5% margin of error, and a 95% confidence interval, we planned to interview 136 ANC and labor and delivery providers. Twenty-two obstetricians, pediatricians, medical officers, nurses, and midwives were selected as data collectors for all the study tools based on their active clinical practice and data collection experience. All data collectors received 2 weeks of training that included a briefing on the background and rationale of the study, an overview of the study instruments and informed consent process, and orientation on all data collection tools, including gender-related aspects of the observational and interview tools and technical instructions for using CommCare technology, the mobile software used for data collection. Data collectors were trained on gender terms and to review records for missing or inconsistent answers before submission. Data collectors practiced using the study instruments in the classroom with colleagues during role plays and clinical simulations using anatomic models and inter-rater reliability of the observers’ scores was tested. Field tests using the tools were conducted over 2 days in five health facilities in Kogi States, and feedback was used to revise the tools and reword questions as necessary. Data collectors worked in teams whose staffing was based on the number of observations to be made and classifications of the health facilities. Data collection lasted 1–2 days in primary health centers and 2–4 days in larger secondary and tertiary health facilities. Repeat visits were made to complete the target number of ANC observations if needed; repeat visits were required more frequently in tertiary health facilities and general hospitals. Supervisors visited data collection teams to provide ongoing quality control. Data were collected in Kogi and Ebonyi States from 1 April through 30 June 2016 and entered directly on android-enabled tablet PCs using custom-created data entry programs developed with the password-protected CommCare software package. Technical and information technology staff monitored data sent to the CommCare HQ online site and verified data completeness and accuracy. Data were exported from CommCare to Excel before being converted to SPSS for cleaning and analysis. Data analyses performed included percent distributions, counts, means, medians and cross-tabulations. Responses to open-ended questions from the provider interview were collated and summarized by theme. Results for Kogi and Ebonyi States were analyzed separately due to significant sociocultural and normative differences in gender and health practices. For example, 74.2% of women in Ebonyi State have undergone female genital mutilation compared to 1.7% of women in Kogi State [1]. Descriptive gender analysis was used to answer the gender assessment questions of the quality of care findings. Gender analysis emphasizes the importance of examining not only supply-side issues in health service provision, but also demand-side issues and the interrelation of the two [42]. Gender analysis can reveal the complex interplay of gender inequality and other inequities that constitute barriers or facilitators for access to health services and provider-client interactions. It can also provide baseline information about providers’ knowledge, attitudes, and practices around gender during RMNCAH service delivery and uncovered gender-related barriers that hinder the provision of quality, respectful, and equally accessible health care. A descriptive analysis of gender-specific quality of care findings was conducted using USAID’s Gender Analysis Framework (Fig. 1) [44, 46] to examine gender-based constraints and opportunities in four domains: (1) Practices, roles, and participation; (2) Beliefs and perceptions; (3) Access to assets; and (4) Institutions, laws, and policies: Gender analysis framework

Izinto zokwakha

N/A

Emisha

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

1. Gender Sensitization Training: Provide training programs for healthcare providers to raise awareness about gender discrimination and its impact on maternal health. This training should focus on promoting gender equality, challenging gender stereotypes, and fostering a more inclusive and respectful environment for women seeking maternal health services.

2. Partner Involvement Programs: Develop initiatives to actively involve male partners in maternal health care. This could include educational programs for men on the importance of their involvement, creating spaces for men to accompany their partners during antenatal visits and childbirth, and providing resources and support for men to actively participate in decision-making regarding family planning and maternal health.

3. Strengthening Referral Systems: Improve the referral systems between different levels of healthcare facilities to ensure that pregnant women have access to appropriate and timely care. This could involve establishing clear protocols for referrals, training healthcare providers on the referral process, and implementing mechanisms to track and monitor referrals to ensure they are being followed up on.

4. Addressing Gender-Based Violence: Integrate services for gender-based violence (GBV) prevention and response within maternal health programs. This could include training healthcare providers to identify and respond to GBV, establishing partnerships with local organizations that specialize in GBV support, and ensuring that women who experience violence have access to appropriate care and support.

5. Community Engagement and Education: Engage communities through awareness campaigns and educational programs to address gender discrimination and promote maternal health. This could involve working with community leaders, religious institutions, and local organizations to disseminate information about the importance of maternal health, challenge harmful gender norms, and encourage community support for women seeking maternal health services.

6. Monitoring and Evaluation: Implement robust monitoring and evaluation systems to track progress and identify areas for improvement. This could involve collecting data on gender-related indicators, conducting regular assessments of healthcare facilities’ adherence to gender-sensitive practices, and using feedback from women and healthcare providers to inform programmatic changes.

These innovations aim to address the gender discrimination highlighted in the study and create a more inclusive and supportive environment for women accessing maternal health services.

AI Innovations Description

The recommendation to improve access to maternal health based on the findings of the study is to address gender inequalities in health service delivery. This can be done through the following strategies:

1. Training and capacity building: Provide training to healthcare providers on gender, gender-based violence, and human rights. This will help them understand the importance of gender equality in healthcare and provide gender-sensitive and respectful care to women.

2. Values clarification: Conduct values clarification sessions with healthcare providers to address any gender biases or discriminatory attitudes they may hold. This will help them recognize and challenge their own beliefs and practices that may hinder women’s access to quality care.

3. Gender-responsive approaches: Implement gender-responsive approaches in healthcare facilities, such as encouraging women to bring their partners to appointments and involving men in health services. This will promote male involvement in maternal health and support women’s decision-making autonomy.

4. Addressing harmful practices: Take steps to eliminate harmful practices during childbirth and ensure that women receive respectful and dignified care. This includes addressing disrespectful or abusive practices and providing information, services, and referrals for gender-based violence.

5. Policy and institutional changes: Advocate for policy and institutional changes that promote gender equality in healthcare. This can include implementing guidelines and protocols that ensure gender-sensitive care, as well as addressing gender discrimination in the workplace.

By implementing these recommendations, it is hoped that access to maternal health will be improved and gender inequalities in healthcare will be addressed.

AI Innovations Methodology

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

1. Gender Sensitization Training: Provide training to healthcare providers on gender equality, gender-based violence, and human rights. This training should focus on addressing gender biases and promoting gender-sensitive and respectful care.

2. Partner Involvement: Encourage healthcare providers to actively involve male partners in maternal health services. This can be done through counseling sessions, educational materials, and creating a welcoming environment for male partners in healthcare facilities.

3. Addressing Harmful Practices: Develop protocols and guidelines to address harmful practices during childbirth, such as disrespectful or abusive practices. Healthcare providers should be trained to identify and prevent these practices, ensuring a safe and respectful environment for women.

4. Referrals for Gender-Based Violence: Establish a system for healthcare providers to offer information, services, and referrals for gender-based violence. This can help women who experience violence access the necessary support and resources.

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

1. Baseline Data Collection: Collect data on the current state of access to maternal health services, including factors such as gender discrimination, male partner involvement, harmful practices, and referrals for gender-based violence.

2. Intervention Implementation: Implement the recommended interventions in selected healthcare facilities or communities. This could involve training healthcare providers, developing protocols and guidelines, and raising awareness among the target population.

3. Post-Intervention Data Collection: Collect data after the interventions have been implemented to assess the impact on access to maternal health services. This could include measuring changes in healthcare providers’ attitudes and practices, male partner involvement rates, reduction in harmful practices, and increased referrals for gender-based violence.

4. Data Analysis: Analyze the post-intervention data to evaluate the effectiveness of the recommendations in improving access to maternal health services. Compare the post-intervention data with the baseline data to identify any significant changes or improvements.

5. Evaluation and Recommendations: Based on the data analysis, evaluate the impact of the interventions and make recommendations for further improvements or adjustments. This could involve identifying successful strategies and areas that require additional attention or resources.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and provide evidence-based insights for future interventions and policies.

Umbhali

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1186/s12913-021-06204-x

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Nigeria

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female

Yabelana ngalokhu: