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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.
