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Background: Preconception care (PCC) services aim to improve reproductive health outcomes through the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs. Countries that have deployed PCC services have policies that guide the services provided. In Nigeria, PCC is poorly developed and is often provided in an opportunistic manner with no guidelines in place to direct the provision. This study explored the opinions of policymakers and health workers about the feasibility of deploying PCC services in the country. Methods: This study was a qualitative exploration of opinions about PCC service deployment within the Nigerian health system in which 39 in-depth interviews were conducted with policymakers at the federal and state tiers of government as well as health workers at the tertiary, secondary and primary levels of health care. The transcripts were analysed thematically using a hybrid of deductive and inductive coding on MAXQDA 2018 qualitative data analysis software. Results: Four main themes emerged from the data—issues around policy for PCC, service integration and collaboration, health system readiness and challenges to PCC service deployment. While noting that the country has no PCC policy, participants identified existing policies into which PCC can be integrated. The participants also described the importance of policy to PCC provision and provided information on existing collaborations that can help the policy development and implementation process. Although many of the participants believed the health system is prepared for PCC deployment, they identified challenges related to policy formulation and implementation, including financial challenges that could hinder the process. Conclusion: Deployment of PCC services in the Nigerian health system is achievable as there are existing health-related policies into which the guidelines can be integrated. However, there is a need to consider the possible implementation challenges and address them as part of the planning process.
This study was a cross-sectional exploration of opinions about PCC service deployment within the Nigerian health system. The study explored the health system at the tertiary, secondary and primary health care levels using in-depth interviews to obtain the perspective of health workers and policymakers. Politically, Nigeria operates a three-tier political system with a democratically elected federal government at the national level, state governments in the 36 states and the Federal Capital Territory, each of which is subdivided into local government areas (LGAs) managed by local government authorities [21, 24]. Within the Nigerian health system, the local government authority manages the development, operation and provision of PHC services under the guidance of the National Primary Health Care Development Agency (NPHCDA) [24, 25]. The state governments perform a technical role—training staff, overseeing the activities at the local government level and providing secondary health services while the federal government provides strategic oversight and manages the tertiary health services [21, 24]. This study used multiple sites across the three tiers of government and the three levels in the health system. For the health system aspect of the study, Oyo State was purposively selected for two main reasons. First, it is one of the urban southern states with good access to health services and better reproductive health indices [21, 26]. Secondly, it has tertiary, secondary, and primary health facilities located in one of its LGAs. The study population included policymakers at the federal and state levels and health workers at the primary, secondary and tertiary levels of care. Using purposive sampling, participants were recruited into the study based on their experience and ability to provide information on maternal and child health issues in the country and within the health system. At the federal and state levels, 13 policymakers were selected from Ministries, and Agencies with links to maternal and child health services. These were the Ministries of Health, Education, Sports & Youth Development, Women Affairs, and the Primary Health Care Development Agency at both federal and state levels. The health workers were purposively selected on the premise of their involvement in maternal and child health services. Working with the varying staff population at each of the three levels of health care, three (3) health workers were selected at the primary level, five (5) at the secondary level and 18 at the tertiary level. All the policymakers and health workers approached for the study agreed to participate. Interview guides containing open-ended questions were developed for the study using information from existing PCC literature. The interview guides were pretested and changes made to ambiguous questions before the study began. The main interview questions for the health workers were: What role is there for preconception care services in your practice? How would you go about integrating preconception care services into your practice? What challenges do you foresee that may affect integrating preconception care into your practice? For the policymakers, the main questions were: How feasible is integration of a formal preconception care service into the existing maternal and child health care services? What opportunities exist for integrating preconception care service into the existing maternal and child health services? What policy opportunities or gaps can you identify as likely to catalyse the integration of preconception care into existing services? What challenges do you anticipate? The first author was responsible for the data collection and conducted all the policymaker interviews. There was no prior interaction between the interviewer and the participants besides the contact made to set up the interviews. However, because she is a Community Physician who has worked with many of the health workers previously, four research assistants were recruited for the health worker interviews. The research assistants were Masters students from the Faculty of Public Health, University of Ibadan, Nigeria who were experienced in qualitative data collection. Being of lower qualification and younger ages than most of the health workers could have affected the research assistants’ ability to probe properly during the interviews. The effect of this was minimised by having debriefing sessions to review each interview and field notes with the first author after each interview. Notes were made on issues that could have been probed further and these were included in subsequent interviews. All the interviews were conducted face to face in the participants’ offices and lasted about 30 to 45 min each. The interviews were recorded with a digital recorder and transcribed verbatim by the research assistants. The first author read all the transcripts and integrated them with the field notes and reflective diaries, comparing them with the audio recordings to ensure there was no missing information. The transcripts were returned to the participants for review and corrections or additions were made as requested. The transcripts were imported into MAXQDA 2018 qualitative analysis software. Thematic analysis using a hybrid of deductive and inductive coding was done [27, 28]. As part of the measures to ensure trustworthiness of the analysis, two independent coders who are not authors on this paper but are experienced in qualitative analysis developed codes deductively by identifying recurrent patterns in four of the transcripts. The first author also coded the same set of transcripts and agreement on final codes was reached during a discussion session by the three coders. The initial set of 25 codes were merged into four main themes, two of which had subthemes (Table (Table22). Themes identified in the study All the study participants were provided with information sheets giving details of the study and consent was obtained for both the interviews and the recording. No identifying information was obtained; the transcripts were de-identified and stored in a password protected computer accessible only to the authors. Ethical approval for the study was obtained from the ethics committee of the University College Hospital (UCH), Ibadan, Nigeria, the Oyo State Ministry of Health, the Federal Ministry of Health, Nigeria and University of Witwatersrand Human Research Ethics Committee, Johannesburg, South Africa.
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