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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
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