Impact of COVID-19 on utilization of maternal, newborn and child health services in Nigeria: protocol for a country-level mixed-methods study

Introduction

The Sustainable Development Goals agenda is part of the global efforts to improve maternal, new-born and child health (MNCH) by challenging countries to make efforts to reduce the global burden of maternal, new-born and child mortality¹. However, despite these efforts, global maternal mortality remains unacceptably high with about 303,000 women dying each year from pregnancy-related complications², for which sub-Saharan Africa and Southern Asia accounts for about 86% of such deaths¹. According to the World Health Organization (WHO) report, an estimated 5.3 million under-5 deaths and 2.5 million neonatal deaths were reported in 2020, which are equivalent to an under-5 mortality rate of 39 per 1,000 live births and neonatal mortality rate of 18 per 1,000 live births, while the maternal mortality rate is 211 per 100,000 live births³.

In Nigeria, MNCH outcomes have improved over the last decade. However, these outcomes are still rated as being among the worst in the world⁴. The under-5 mortality rate is 132 deaths per 1,000 live births while the infant mortality rate is 67 deaths per 1,000 live births⁴. On the other hand, the maternal mortality ratio in Nigeria is 512 per 100,000 live births and some of the main causes of maternal deaths include obstetric haemorrhage, infection, obstructed labour, unsafe abortion, preeclampsia/eclampsia, malaria, anaemia, and contributory factors such as lack of awareness about complications in pregnancy, inability to seek timely medical intervention, lack of utilization of health care services, lack of transportation and inability to pay for services^4,5. With these indices, Nigeria is the second largest contributor to maternal mortality worldwide accounting for more than 10% of all cases^2,5.

In order to improve child survival and maternal health, the continuum of care for MNCH was designed and this has gained so much attention because it is expected to reduce the burden of maternal deaths, neonatal deaths and deaths among under-5 children particularly in lower and middle-income countries^6,7. The continuum of care includes healthcare services for mothers and children from pre-pregnancy to delivery, postnatal and childhood^6,8. Furthermore, this depicts the link between maternal and child health, particularly as they seem to be affected by the same variables. Therefore, this makes it important that at every specific point in the continuum of care, every mother/child pair should receive the full package to attain maximum satisfaction⁶. Towards a positive impact on overall MNCH indicators, every woman is expected to continuously receive antenatal care (ANC), skilled birth attendance at delivery and postnatal care (PNC). The WHO recommends that every pregnant woman is expected to have a minimum of eight ANC contacts before delivery⁹. This is because ANC helps to identify pregnancy risks, provide appropriate care for women who might be at risk of potentially fatal conditions, provide opportunities for counselling these women and give access to health-promoting services (weight measurement, blood pressure measurement etc), and it also helps to increase subsequent use of maternal and child health services^7,10. Even though the majority of maternal and neonatal deaths occur in the postpartum period, in Nigeria, only about 42% of mothers utilize PNC services within the first two days after delivery. Similar trends are seen in the utilization of ANC, the number of deliveries attended by skilled birth attendants and uptake of immunization and family planning services. According to the Nigerian Demographic and Health Survey 2018, only 57% of women had at least four ANC visits, deliveries by skilled birth attendants were 43%, immunization coverage for age-appropriate vaccinations was 21%, and modern contraceptive prevalence rate among currently married women was 12%⁴.

Low utilization of MNCH services can be categorized into two major factors, which are the user factor and the health system factor. The user factor includes distance to a health facility, cultural beliefs and practices, economic factors and many other factors within the community and respective households. On the other hand, the health system factor includes the capacity of health staff, attitude of care providers, infrastructure and other forms of interactions that take place within the healthcare system¹.

With the recent COVID-19 pandemic, the resilience of health systems’ and countries’ emergency preparedness and response have been tested. According to the WHO, over 200 countries, areas and territories have been affected and as such health systems have been critically affected¹¹. As of May 17, 2020, there have been 4,534,731 cases of COVID-19 and over 307,537 deaths globally. In Africa, about 58,663 cases and 1,710 deaths have been recorded. On the other hand, in Nigeria, 5,621 cases and 176 deaths have been recorded¹². COVID-19 pandemic and its devastating impact on the health systems, livelihood and economies of Nations have been likened to a “war” situation. Health care for women and children are usually disproportionally and negatively impacted at times of war and conflicts. Battling with COVID-19 and providing essential services along the continuum of care is critical and challenging⁴. To avert deaths, it is important to ensure that appropriate care is available to every woman and every child during the pandemic. We, therefore, hypothesized that COVID-19 pandemic in Nigeria may have further worsened the already poor maternal and child health services utilization in Nigeria. Thus, this study is designed to evaluate the impact of COVID-19 on the utilization of MNCH services in Nigeria using a mixed-method approach. The quantitative part of the study will involve the collection of longitudinal data on maternal and newborn health services, while the qualitative component will explore the barriers being experienced by women and their families in getting access to MNCH services as well as other contextual factors that may have shaped the utilization of MNCH services during the COVID-19 pandemic. It would also explore the level of preparedness of the Nigeria health system in responding to such pandemics and examine the available policies and action plans that are currently in place. Findings from this study will be beneficial in providing key stakeholders at all levels of the health care system with the necessary information that will provide new direction and policy for the country towards mitigating the negative impact of COVID-19 on the already fragile health system, and thus help in sustaining previous efforts towards attaining the third sustainable development goal of “achieving good health and well-being for all” in Nigeria.

Aim and objectives

The study aims to assess the rate of utilization of maternal and newborn child health (MNCH) services before and during the COVID 19 pandemic as well as to critically examine the various barriers and facilitators associated with accessing MNCH services during the COVID-19 pandemic in Nigeria. Specific objectives are to:

Protocol

Theoretical frameworks

Several theoretical frameworks have been developed that may have relevance to exploring and understanding barriers to the utilization of health care services. We will use a hybrid of the social-ecological model (SEM) and the three delays model to investigate and explore how COVID-19 has impacted on utilization of MNCH services in Nigeria. The SEM provides a theory-based approach to understanding the complex interaction between individual, interpersonal, community, institutional and policy factors that influence behaviour and practice¹³. The delay model recognizes three phases (delay in deciding to seek care, delay in reaching healthcare facility and delay in receiving adequate care at the health facility) as contributing to women’s ability to receive care towards averting poor outcomes. These delays are shaped by several complex factors operating at the same or different levels of delays^14–16. Figure 1 shows the theoretical frameworks to be used for this study.

Figure 1. Summary of interactions between the social ecological model, three delays model and utilization of MNCH services.

Ethical considerations

Ethics approvals have been obtained from the Health Research Ethics Committee of the participating tertiary hospitals involved in the study: University of Abuja Teaching Hospital (UATH/HREC/PR/2020/001), Lagos University Teaching Hospital (LUTHHREC/EREV/0520/42), University of Nigeria Teaching Hospital, Enugu (NHREC/05/01/2008B-FWA00002458-1RB00002323), Mohammad Abdullahi Wase Teaching Hospital, Kano (MOH/Off/797/T.I/2060), Federal Medical Centre, Yenagoa, Bayelsa (FMC/ADM/017/Vol.1/138), Federal Medical Centre, Jalingo, Taraba (FMC/JL/ADM/330). Social approval and permission will be sought from the primary and secondary facilities selected for the study. The ethical review undertaken by all project investigators will ensure standard processes (dignity, autonomy, informed consent, confidentiality, anonymity, ability to adhere to protocol) and data security are maintained. Voluntary and informed participation, confidentiality and safety of participants will constitute key principles of researcher–respondent interaction. Written consent will be obtained from service users, service providers and policymakers prior to their enrolment in the study. The study will be conducted according to the Helsinki declarations on ethical principles for medical research involving human subjects.

Patient and public involvement, and dissemination

The development of the research question was based on experiences of patients narrated in the media, as well as during medical consultations at the obstetric emergency services of the University of Abuja Teaching Hospital, Abuja. Their inputs were sought in designing the qualitative component of the study proposal.

Findings from this study will be disseminated by delivering presentations at national and international conferences, organization of study dissemination meetings involving relevant stakeholders in Nigeria and publishing articles in peer-reviewed journals. Additionally, all participating institutions and patients will be notified of the key findings from the study. Data resulting from this study will be deposited in a data repository (Mendeley Data) and can be assessed by the public.

Study status

The study is currently collecting both longitudinal data and qualitative data.

Discussion

This paper reports a protocol for an observational mixed-methods study design aimed at collecting quantitative data showing the trend of utilization of MNCH services during the three months preceding and during the COVID-19 pandemic, and qualitative data from key stakeholders across the health systems in the six geopolitical zones in Nigeria to determine the barriers and facilitators associated with access to MNCH services during the COVID-19 pandemic. Additionally, the study will explore other contextual issues that have shaped service delivery along the MNCH continuum of care during the COVID-19 pandemic. The study findings will provide a timely contribution to the ongoing debate on the magnitude of impact on access and utilization of MNCH services across the different levels of the Nigeria health system following the COVID-19 outbreak and also help in identifying strategies that will assist Nigeria and other African countries in maintaining focus towards the realization of the third sustainable development goal of “ensuring good health and well-being for all” amidst the COVID-19 pandemic.

Conclusion

The identification of the state of MNCH continuum of care and the most affected components of care during the COVID-19 pandemic in Nigeria could lead to multiple benefits for service users, service providers, policymakers and other relevant stakeholders towards effective planning for the strengthening of national health systems during the COVID-19 pandemic.

Data availability statement

No data are associated with this article.