Menu
Menu
Menu
Menu
Objective The objective of this paper is to explore policy-makers and clinical managers’ views on maternal health service delivery in rural Nigeria. Design This is a qualitative study using key informant interviews. Participants’ responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery. Setting The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria. Participants The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter. Results Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents’ notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints. Conclusion This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.
This study uses a qualitative research design within which thematic analysis was applied. Thematic analysis is a method for identifying, analysing and reporting themes within data.16 The authors applied this method in its contexualist sense, meaning that through this method, the authors acknowledge ways individuals make meaning of their experience and also how those meanings are influenced by the broader context. Specifically, the authors applied a theoretical thematic analysis whereby analysis is driven by a theoretical knowledge of service delivery.16 This study uses data from key informant interviews in rural Edo State, Nigeria and focuses on maternal healthcare service delivery from the perspective of policy-makers and clinical managers. Key informant interviews are in-depth interviews with individuals possessing particular knowledge and understanding of a subject matter. The authors deemed policy-makers and clinical managers key informants based on Gilchrist and Williams’s description of key informants.17 These are individuals who possess essential knowledge of the subject matter and have access to perspectives or observations that would ordinarily be inaccessible to the researcher.17 Our findings were reported based on the Consolidated Criteria for Reporting Qualitative Research (see online supplemental file 1). fmch-2021-000994supp001.pdf This study was conducted in Edo state, one of Nigeria’s thirty-six States. Specifically, this study was conducted in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas (LGAs) of Edo state with 10 political wards each. These study sites were chosen because preliminary baseline assessments revealed high maternal mortality rates and low use of PHC facilities.18 ETE is located in the northern part of Edo State and comprises of 213 940 residents, while ESE is located in the southern part with 241 492 residents in 2020. The principal source of maternal healthcare in the two LGAs is PHC. ETE has 28 PHC centres and two general hospitals (secondary health facilities), while ESE has 25 PHC centres and one general hospital. The study consisted of 13 stakeholders from different institutions in ESE and ETE. Participants included one senior official with the State Ministry of Health, one senior official with the State Primary Healthcare Development Agency, two senior officials responsible for PHC at each LGAs, two senior LGA officials, and seven clinical managers in PHC centres. Key informants were chosen using a purposeful criterion sampling technique.19 The criteria for selection was that participants were in a key leadership position within the PHC sector. The lead investigators (FEO, WI and LFCN) contacted each participant by email (or phone) with information about the study, voluntary participation, and informed consent. Sample size was determined with a focus on attaining thick and rich data.20 Following recommendation from studies and observing that in-depth interviews generally adopt a sample size of multiples of 10, this study purposefully recruited participants from different backgrounds and professions with the goal of obtaining detailed, nuanced and intricate data.20 21 The lead investigators (FEO, LFCN) conducted a 3-day training session for the research assistants who carried out this study. The training focused on the following factors: goals of the research, the art of qualitative data collection, using key informant interview guides in qualitative research, the role of the data collector, research ethics and data collection using electronic devices. The lead investigators developed a key informant interview guide and on the last day of training, the trained research assistants moderated the pilot of the guide in a community with similar characteristics to the study site. The key informant interview guide was moderately structured to allow for free description of opinions and experiences. The trained research assistants conducted 13 key informant interviews. All data were collected in English between 16 July 2017 and 30 August 2017. The research assistants audio recorded the interviews and took reflective field notes to supplement the transcripts. Interviews lasted for 45 min on average and ended when no further issues arose. The key informant interview guide consisted of open-ended questions and follow-up probes on stakeholders’ perceptions of maternal healthcare service delivery across PHCs in rural ESE and ETE communities. The interview guide was developed based on the authors’ experiences with influence from existing literature on service delivery. A full description of the key informant interview guide is available (see online supplemental file 2). fmch-2021-000994supp002.pdf A sample of issues discussed with participants include: The primary author (OU) and corresponding author (SY) analysed the data, and the coauthors validated the data. The authors compared the transcripts with the audio recording and field-notes to ensure accuracy. In analysing the data, the authors applied an iterative process of inductive and deductive approaches to thematic coding. Following the recommendation of data analysis from Braun and Clark,16 the authors became familiar with the data, then proceeded to generate codes, then searched for themes, reviewed and defined themes. This was in line with an inductive approach to coding where themes emerged from the data not from any preconceived categories. The data was further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery.12 Themes were generated as follows: line-by-line reading generated words or phrases with similar meanings that were linked to the study’s aim and existing literature on service delivery of maternal healthcare in rural Nigeria. These findings were categorised, noted, and subsequently grouped into a coding scheme with the purpose of creating subcategories. Subcategories gave a more general description of the content. Similar subcategories were grouped to formulate main themes. Multiple coders (SY and OU) worked independently to analyse the transcript, manually code the interview data using free codes and develop the various themes. To establish inter-rater reliability and ensure trustworthiness of the study, the coders conducted frequent discussions to examine consistency during the individual process of coding. The coauthors audited the data analysis and reached a consensus on emerging themes. Please see box 1 for definitions of key themes under which findings were reported. Participants’ views of maternal healthcare service delivery in rural Nigeria are presented in five overarching themes. These themes are in consideration of the WHO’s key characteristics of good service delivery.12 This qualitative study used various strategies to enhance trustworthiness of the data. The interview guides were structured to allow for iterative questioning including the use of probes to elicit detailed data, and questions were rephrased to participants when necessary.22 After data collection, FEO and LFCN conducted member checks to ensure accuracy of the data. The coding process involved two coders (SY and OU) working independently to code the data and collaboratively to generate themes. The principal investigators FEO, SY and LFCN who have ample experience in reproductive health in sub-Saharan Africa audited the findings and provided feedback. Triangulation is important in promoting confirmability.22 This study approached triangulation via data sources by interviewing a wide range of key informants. In writing up the manuscript, the author (OU) described the aim of the research and provided thick descriptions of participants’ responses, alongside relevant quotes to confirm interpretations. Quotes were also chosen to represent a typical response relative to the theme. These were necessary to enhance confirmability.23 Patients and the public were not involved in the design and conduct of this research.
N/A
