Comprehensiveness

Study participants depicted PHC centres as providing a wide range of maternal healthcare services to women. As part of primary care, pregnant women received preventative services such as antenatal care and health promotive services focused on healthy nutrition and personal hygiene during pregnancy. PHCs offer family planning services including a constant supply of contraceptives to women. Participants commented on the range of services available in PHC centres.

Nationally, we have this free malaria program for pregnant children and children under 5…You have programs to eliminate mother to child transmission of HIV… You also have programs on nutrition…programs are running on increasing access to family services. (Senior official, Ministry of Health)

We teach and encourage some women to do backyard garden. (Clinical manager, ESE)

Furthermore, participants’ comments demonstrated a strong partnership between PHC centres and the community in designing and implementing acceptable maternal health services. Beyond the provision of health services, some PHC centres enhanced the efforts of communities to build water tanks. Clinical managers explained that they prioritised a good working relationship with the community.

We summoned chiefs in all the quarters, they came there, we let them know what is happening here [PHC], so that it will not look like a taboo to them, We asked them to encourage their people to accept [PHC], with that the chiefs went out to build the relationship [with the community]. (Clinical manager, ESE)

These positive reports notwithstanding, some participants felt that PHC centres did not provide a range of maternal health services. Participants felt that PHC centres were ill equipped to provide basic maternal healthcare. For instance, pregnant women were unable to undergo routine screening and testing at PHC centres due to the shortage of equipment. Women were often referred to secondary or tertiary health facilities to receive basic maternal healthcare. These facilities were often outside of their communities, thereby causing delay in reaching care.

So, we are trying to look for some basic things but [PHC] facility does not have a glucometer to instantly check the blood sugar of a patient in antenatal. (Senior official, PHC, ESE)

Accessibility and coverage

Participants reported that even with the range of maternal healthcare services currently provided in PHC centres, there were disparities in healthcare access and utilisation of various services. Factors such as out-of-pocket costs for services and the physical accessibility of PHC facilities meant that compared with wealthier women, women of low socioeconomic status in rural areas were less likely to receive maternal healthcare. There were discrepancies in perspectives of coverage between policy-makers and clinical mangers. Some policy-makers in the ESE region believed that maternal healthcare services and basic medication during pregnancy were provided free of charge to women. A policy-maker commented:

Here even delivery is free, government policy, except it is not a normal delivery, then there may be some charges, but if it is normal it is free. Malaria treatment for instance for pregnant mothers and zero to five is also free, drugs are very available and are also free, so people are aware of these incentives and they try to take advantage of it. (Senior local government official, ESE)

Other policy-makers in the same region, however, did not share this view because women were often required to pay out of pocket for basic maternal healthcare services, which were supposed to be free of charge. For instance, some PHC centres required that pregnant women provide basic medical supplies such as surgical gloves and cord clamps, prior to assisting with deliveries. In addition, patients pay out of pocket for drugs and routine medical screening. Participants also noted that in some cases, the financial costs of PHC could get so expensive that it amounted to the same as secondary healthcare costs. Participants were concerned that these factors have added up to make maternal services unaffordable for most of the rural population, particularly poor families. Policy-makers and clinical managers asserted that offering free maternal health services would improve women’s use of PHC centres for maternal healthcare services.

It is supposed to be free to deliver, you know, but if a woman comes to deliver, provision of things like surgical gloves for you to be able to take a delivery is one of the criteria and then little things like cord clamps, but [after delivery], they pay 2000 naira [~$5 USD] (Senior Official, PHCs, ESE)

[primary] health centre is supposed to be cheaper than general (secondary healthcare), but sometimes, you see the bill being the same because of no drugs (Clinical manager, ETE)

Furthermore, participants indicated that access to maternal care services was hampered by distance to PHC centres. Moreover, bad roads and lack of reliable transportation deterred women’s access to maternal health services. Participants cited the need for more PHC centres because current centres were operating beyond capacity.

The distance to PHCs, those that really live very far can really find it very difficult to access the PHCs. Therefore, PHCs really need to spread out more and maybe on a ratio to population. PHCs ratio shows a little lower than what it is now. We have so many people attending just one PHC or being serviced by one PHC, so we want many more PHCs so that many more people will have where to go. I think that is what has reduced their usage. (Senior official, PHCs, ETE).

Participants indicated that factors related to beliefs, and nature of relationship with providers play a role in women’s access to maternal healthcare services. Participants described efforts to make services accessible to communities. They reportedly enhanced the acceptability of services by consulting community members and encouraged their participation in designing and delivering health programmes. However, participants highlighted issues related to the nature of interactions between patients and healthcare providers. Healthcare workers were reportedly harsh and abusive to women, and this discouraged their use of PHCs for maternal care.

Another thing is the relationship of the nurse to the patient, do you understand? There are some people [nurses] who are harsh to them [patient] so they may change health facility. (Clinical manager, ETE)

While participants’ views gave a general sense that maternal health service delivery was not always designed to cover all women seeking care, some applauded existing initiatives that aimed to increase the coverage of maternal healthcare services. One of such initiative is the drug revolving fund, a drug management initiative aimed at making essential medication accessible and affordable, particularly to pregnant women and children. The drug revolving fund initiative reinvests revenue from the sale of drugs in the purchase of new drugs thereby making them more accessible and affordable in PHC centres.

The LGA has released One Million Naira (~$3000 USD) for Drug revolving fund because no matter how beautiful a health centre is, no matter how equipped the state of the art, material, no matter how much, I mean the number of staff you have updated, if there are no drug, there is nothing you can do especially when a woman delivers (Clinical manager, ESE)

Quality of service

Quality maternal healthcare services particularly during pregnancy and childbirth were reported as the exception rather than the rule in rural communities. In the case of pregnancy care, participants linked quality care with adverse pregnancy outcomes. A PHC centre was reported to deliver quality skilled pregnancy care if there was an absence of adverse pregnancy outcomes such as stillbirths, prepartum/postpartum haemorrhage, and maternal deaths in the past year. Participants linked the quality of maternal health services to the provision of skilled care by qualified healthcare personnel. An overwhelming number of participants across the different LGAs expressed displeasure over the extreme shortage of the health workforce which has resulted in unsafe and inefficient service delivery. The shortage of doctors or midwives in rural PHC centres often meant that unqualified healthcare staff handled obstetric emergencies. There were reported instances of maternal deaths during obstetric emergencies due to the absence of qualified healthcare workers. A clinical manager described the current situation of staff shortage in rural communities:

Yes, for instance in all the health centers in this LGA, we just have one. One nurse per center but at least you are supposed to have four, four personnel on ground so that if one does morning, the other afternoon, the other one night. At least we should have one maybe on leave but in this case we have just one staff who runs 24 hours duty today, tomorrow, the same thing. So, there is shortage of staff, I mean a qualified nurse midwife in this local government, we are very much short staffed. (Clinical manager, ESE)

There are ongoing efforts to improve the quality of care provided by healthcare staff in rural PHCs. Policy-makers and clinical managers attested to various human resource training and skill enhancement opportunities in the PHC sector provided by various non-governmental organisations. They reportedly received training on a range of topics including immunisation, malaria treatment, skilled pregnancy care, healthcare management, drug revolving scheme and legal matters. Respondents believed that opportunities for training were impactful in boosting the morale of healthcare staff and keeping them motivated while on the job. Additionally, trainings were viewed as important in expanding the knowledge base of healthcare workers, particularly lower-trained cadre of workers such as community health workers. Participants felt that basic pregnancy care training for community health workers would prepare them to assist during obstetric emergencies, which will go a long way in reducing maternal morbidity and mortality. However, training opportunities were not always distributed fairly as healthcare workers with relatives and friends in power were more likely to get more training and skill enhancement opportunities than other healthcare staff. Participants called for a more equitable distribution of training opportunities among healthcare workers to improve the quality of care.

The issue is that sometimes they organize trainings, and it is the same set of people that keep going because they are connected. So, we need to organize trainings in such a way that it goes round, everybody has an opportunity to be trained not just the same people just because they are connected in one way or the other. So, there is issue of training (Senior official, SPHCDA)

Respondents also considered quality of care in the context of cleanliness of the health centres. Quality indicated the capacity of PHCs to offer clean and hygienic care to women. Most health facilities were reportedly lacking consistent water supply and adequate toilet facilities. Furthermore, participants expressed negative views related to apathy, abusive practices of healthcare providers, and the lack of basic and life-saving equipment. Women were mistreated when seeking care in PHCs and services were delayed. Participants discerned that these conditions discouraged women’s use of health facilities. Participants generally believed that more maternal deaths occur in underfunded, underequipped and understaffed PHCs compared with equipped facilities.

We have either obsolete knowledge, obsolete equipment and obsolete skills and all these things affect the overall effectiveness of health services and the satisfaction we get from it in our health facilities. (Senior official, PHCs, ETE)

Person-centredness and coordination

While participants agreed that PHCs were lacking in infrastructure and quality service, they believed that maternal health services were person-centred. They viewed services provided to patients as acceptable and responsive. Clinical managers reported being truthful and open in communicating health issues with pregnant women. They made pregnant women aware of any pregnancy complications when detected and swiftly referred them to secondary healthcare facilities when necessary.

Clinical managers across different PHCs reported that they worked collaboratively with their teams of healthcare workers to discuss appropriate care plans and procedures for patients. Clinical managers would occasionally refer women to better-equipped private facilities when necessary. A participant commented on services provided in PHC centres:

So, there are a host of advises you can give to the woman if they come to the hospital [PHC] which TBA [traditional birth attendant] will not be able to offer. I have a host of colleagues, either in private or in Irrua specialist hospital, around this place that I can call, so we can refer them to such people. Even the general hospital at Ewohimi, at Uhaikphen, the Doctor there is even a Gynaecologist. We have been collaborating in that area recently and we discuss a lot. (Senior official, PHCs, ESE)

Coordinated service delivery is represented by an actively coordinated service network across different levels of care and involving multisectoral collaboration. Narratives of participants indicated some level of coordination of care, which involved collaboration with other levels of care and other types of health providers. Participants commented on having an effective referral system, but there was no mention of provision for transportation to facilitate referrals.

I don't think we have a lot of people dying in the PHC. The reason being that the referral system is working so when they get cases that are serious, they usually will refer. Most of those death will occur on the secondary facility and not in the Primary Health Care Centres. (Senior official, Ministry of Health)

Accountability and efficiency

Participants expressed their discontent over the lack of cohesive and efficient management of health services in PHC centres. Different government bodies coordinate various aspects of PHC such as infrastructure, health programming and staff wages thereby leading to a fragmented system. Participants explained that a fragmented system has amplified gaps in PHC infrastructure, human resources management, and access to basic medical equipment, all of which have implications for service delivery. For instance, healthcare staff are not deployed to PHCs based on need. Therefore, PHCs end up with far too many administrative staff while lacking key healthcare workers. Furthermore, healthcare workers were lacking adequate support, supervision and accountability. Participant believed that PHC management generally lacks transparency and accountability.

There is so much fragmentation. So right now, we are trying to get it to be under one management, under one authority. So that there is one body regularizing everything, there will be one body in charge of discipline. So, somebody does not come to work, he is going to be disciplined. Somebody ensures that things are in place, there is security, there is equipment, there is [labour], there is funding. We will employ people that we need, not having so many administrative staff, meanwhile the key health personnel are lacking. By the time there is a body in charge of all that, less interference from politicians, I think this PHC will actually work. (Senior Official, SPHCDA)

Participants noted ongoing policy reforms to address issues of efficiency and accountability within rural PHC system. Policy-makers at the state and local government levels were making plans to implement a Primary Health Care Under One Roof policy which aims to address issues of fragmentation by integrating PHC under one authority. Participants believed that the policy would enable PHCs run effectively and in turn improve pregnant women’s uptake of skilled maternal care services at PHCs.

The PHC’s have been in existence for over a hundred years and yet the situation of things has not improved. I think with this PHC Under One Roof Policy that is being promoted, we are hopeful that things will get better. (Senior Official, SPHCDA)