Supply and Demand Barriers to PHC Maternal Care Services Uptake: Qualitative and Behavioral Insights from Gombe State, Nigeria

doi:10.21203/rs.3.rs-4850092/v1

Download PDF

Research Article

Supply and Demand Barriers to PHC Maternal Care Services Uptake: Qualitative and Behavioral Insights from Gombe State, Nigeria

https://doi.org/10.21203/rs.3.rs-4850092/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Several factors influence maternal care-seeking decisions at primary healthcare facilities. Given the high maternal morbidity and mortality in northeast Nigeria, this study, rooted in the Social Ecological Model (SEM) of behaviour change, investigated the structural and cognitive barriers that limit antenatal and family planning care-seeking behaviour among households in Gombe State, Nigeria.

Method: Qualitative in-depth interviews (IDIs), each lasting 60-70 minutes, were conducted with 56 respondents, including mothers/expectant mothers (n=15), their household decision-makers/spouses (n=16), community leaders (n=16), and primary healthcare centre (PHC) service providers (n=9). The qualitative instrument was developed and analysed based on the four core elements of the SEM: individual, relational, institutional, and community-level factors. The study was conducted in Dukku, a rural local government area (LGA), and Yamaltu Deba, a peri-urban LGA.

Results: The findings indicate that the direct and indirect costs of care, service quality, and PHC proximity were the main supply-side barriers rooted in institutional-level factors. Most of the demand-side barriers were associated with individual (poor salience), relational (limited spousal support), and community-level (traditional maternal practices) factors of the SEM model. Optimism bias, overconfidence bias, and present bias are some of the demand-side psychological barriers that impede maternal care uptake. Similarly, supply-side barriers, such as poor quality of care, can significantly undermine individual and community-level demand for PHC-based maternal care.

Conclusion: The SEM model offers a comprehensive framework for understanding the complex, multi-layered factors influencing care-seeking behaviours toward antenatal care and family planning.

Behaviour

health-seeking

maternal care

antenatal care

family planning

cognitive biases

barriers

supply-side

demand-side

and Social Ecological Model (SEM).

Maternal morbidity and mortality remain critical global issues, with an estimated 287,000 women dying during and after pregnancy and childbirth in 2020 [1]. Hypertension, sepsis, and haemorrhage are leading preventable causes of maternal mortality worldwide and in Nigeria [2, 3]. While maternal mortality has declined in high-income countries, low- and middle-income countries (LMICs) accounted for over 90% of maternal deaths in 2020 [1]. Sub-Saharan Africa (SSA) has some of the highest maternal mortality rates, with Nigeria reporting 1,047 deaths per 100,000 live births in 2020 [4].

The high rates of maternal mortality and morbidity negatively affect the welfare of newborn children but also have severe socioeconomic consequences for households and communities [5, 6] such as diminished productive labour in sectors like agriculture that benefit from female labour. Access to skilled birth and maternal care services at primary healthcare facilities has been shown to significantly reduce maternal and child morbidity and mortality in LMICs [5–7]. Notable initiatives such as the World Health Organization (WHO)'s Ending Preventable Maternal Mortality (EPMM) strategies and efforts to enhance health service provider capacity in SSA [8], and the Community Health Influencers, Promoters and Services (CHIPS) Programme, established by the Nigerian National Primary Health Care Development Agency (NPHCDA) are easing the gaps in maternal care, however, more effort is needed to raise maternal care outcomes in Nigeria to international standards.

Supply-side challenges, including limited functional primary healthcare centres (PHCs) [9, 10], insufficiently trained staff, and poor service delivery attitudes, have been highlighted as the major contributors to low maternal care uptake [10]. However, efforts to address these supply-side issues to increase uptake of PHC services over the past decade have had limited success, particularly in northeast Nigeria [11]. On the demand side, factors such as spousal support and lack of salience have been shown to be significant barriers to the uptake of PHC services in Nigeria [10, 12]. Therefore, it is crucial to explore both supply-side challenges and demand-side psychological barriers to health-seeking behaviour in an integrated manner.

This study is grounded in the Social Ecological Model (SEM) developed by Bronfenbrenner [13] and widely used to understand health-seeking behaviour. The application of this model seeks to enhance the understanding of barriers to maternal health-seeking behaviour by examining the interaction of structural supply-side and psychological demand-side factors affecting antenatal care (ANC) and family planning (FP) uptake at PHCs in Gombe State, Nigeria. The SEM model advocates five core levels influencing decision-making: individual, interpersonal/relational, institutional, community, and policy [13–15]. This study will focus on the first four levels—individual, relational, institutional, and community—given their direct connection to healthcare behaviour. The individual level of the SEM represents individuals’ characteristics, including knowledge, attitudes, beliefs and practices that weigh on decision-making. The interpersonal or relational level of the SEM describes how individuals’ familial and social relationships impact decision-making around healthcare. The institutional level describes the roles and influence of service providers (health facilities) on health-seeking behaviour. Finally, community-level factors can be loosely described as the effect of community social influences on decision-making such as community leaders, widely held community beliefs and practices, and traditions [14–16].

The study explores these research questions: (a) What is the level of knowledge about maternal care services, including antenatal care and family planning, among women and their household decision-makers? (b) What are women’s experiences seeking maternal care at a primary healthcare centre (PHC)? (c) What cultural and religious beliefs affect maternal care and family planning? (d) What are the experiences of primary health care providers in delivering maternal care?

Through the application of the SEM model, this study aims to contribute to qualitative research on the barriers to maternal care uptake and bridge the gap in qualitative evidence on the supply-side and demand-side psychological barriers to maternal care uptake in Gombe State, Northwest Nigeria.

Study design

This study used a qualitative research approach consisting of In-Depth Interviews (IDI) to explore key barriers guided by four core elements of SEM (individual, relational, community, and institutional levels barriers). The study team followed the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ) in the design and implementation [17]. The study focused on gathering qualitative insights from Gombe, northeast Nigeria.

Study sample

The study sample included 56 respondents from both demand and supply sides of PHC maternal care, spanning all four levels of the Social Ecological Model (SEM). It comprised: (a) recipients of maternal care (mothers and expectant mothers); (b) household decision-makers influencing health-seeking behaviour (husbands and mothers-in-law); (c) community influencers (traditional and religious leaders); and (d) maternal service providers, including Community Health Influencers, Promoters, Service agents (CHIPS), and PHC maternal staff (nurses). A total of 56 participants took part in the qualitative study, with the sample size determined based on the expected saturation level for each respondent category [18].

Purposive sampling was used to recruit respondents who met any one of the following criteria: pregnant women aged 18 or older, mothers aged 18 or older with young children (0-5 years), spouses of the recruited expectant mothers or mothers, community leaders (such as traditional village heads and religious leaders), and personnel providing maternal care services or support at a PHC, including community health volunteers. All recruited respondents provided both verbal and written consent.

Data collection and questionnaires

Four semi-structured qualitative questionnaires/guides were created for the four respondent categories outlined in the Study Sample section. These guides, designed to explore barriers to maternal health-seeking behaviour using the SEM framework, were initially developed in English and translated into Hausa language to ensure comprehension. The guides were piloted with two respondents from each category, and feedback from these pilots was used to further refine the interview guides.

Interviews were conducted by trained and experienced qualitative researchers and public health professionals. Participants could choose to be interviewed at a central public location, at a PHC or their homes. Each respondent received an overview of the study objectives and had the opportunity to ask questions before, during and after participation. Interviews lasted between 60 and 70 minutes, were recorded, transcribed, and translated into English. The study team reviewed all transcribed data before synthesis. Data collection was completed between September 2022 to October 2022.

Study location

The study was conducted in two Local Government Areas (Dukku, rural and Yamaltu Deba, a peri-urban) of Gombe State, Nigeria. The state was chosen due to its relatively high maternal and child casualty rates (1,047 deaths per 100,000 live births in 2020 [4]) and comparatively lower levels of insecurity in northeast Nigeria. [19].

Table 1: Thematic breakdown of the qualitative guides

Data Analysis

The qualitative data from the IDIs were analysed using thematic analysis, which consisted of analysing and reporting patterns within data and grouping them under relevant recurring themes [20]. Each interview transcript was reviewed and validated by a second researcher in the study team. The transcripts were coded manually using a data stripping matrix in Excel to collate and identify concepts and insights around barriers to maternal care uptake that address the research questions. The qualitative insights identified were divided into supply-side (structural) and demand-side themes which were linked to common psychological/cognitive biases through behavioural science literature. The SEM model was used to synthesise the supply and demand side insights by highlighting and expanding on the levels of the SEM model (individual, relational, institutional, and community) that explained each of the thematic supply and demand side insights. This thematic analysis approach allowed the authors to identify what elements of the SEM model underpin supply and demand side barriers.

Participant description

The study included 56 participants across four categories: 29% were household decision-makers, 29% were community influencers, 27% were mothers or expectant mothers, and 15% were PHC service providers. See Table 2.

Table 2

Sample breakdown of respondents in Gombe State, Nigeria (n = 56)
Participant Category	Description	Number
PHC Service Providers	Personnel who delivered or supported service delivery for maternal services at PHCs	9
Household Decision Makers	Husbands, mothers-in-law, and fathers-in-law with significant influence over the health decision-making of mothers and expectant mothers in their homes.	16
Mothers and Expectant Mothers	Women with adolescent children and pregnant women.	15
Community Influencers	Traditional leaders who understand the cultural and social dynamics of their community and influence healthcare-seeking behaviour.	16

Most mothers and expectant mothers interviewed were from Yamaltu Deba LGA (53%). The women interviewed were predominantly aged 26 to 30 years (40%), with most having secondary education (33%) as their highest level of education. Most of the mothers and expectant mothers were either unemployed (40%) or engaged in petty trading (40%). All participants were married with at least one child, except for one who was widowed. Most of the respondents had 0–2 children (47%). See Table 3.

Table 3

Demographic breakdown of mothers and expectant mothers
Expectant Mothers and Mothers (n = 15)
Characteristics		Local Government Area (LGA)		Total
Characteristics		Dukku (n = 7)	Yamaltu Deba (n = 8)	Total
Type	Expectant mother	4	4	8
Type	Mother	3	4	7
Highest education	No education	1	0	1
	Primary education	2	0	2
	Secondary education	1	4	5
	Islamic/Quranic education only	3	1	4
	Tertiary education	0	2	2
Occupation	Trader	1	5	6
	Business owner	1	1	2
	Employed	0	1	1
	No occupation	5	1	6
Age	20–25	1	1	2
	26–30	4	2	6
	31–35	2	3	5
	36–45	0	2	2
Marital status	Married	7	7	14
Marital status	Widowed	0	1	1
Number of children	0–2	2	5	7
	3–5	3	0	3
	6 or more	2	3	5

Household decision-makers were predominantly husbands (63%), with primary education being the highest level of schooling for half of them (50%). Most of the husbands interviewed were petty traders (50%). The average age range for husbands was 38–40 years, while mother-in-laws were generally between 50–56 years old. See Table 4.

Table 4

Demographic breakdown of household decision-makers
Household decision makers (n = 16)
Characteristics		Local Government Area (LGA)		Total
Characteristics		Dukku (n = 6)	Yamaltu Deba (n = 10)	Total
Type	Husband	4	6	10
Type	Mother	2	4	6
Highest education	No education	2	1	3
	Primary education	3	5	8
	Secondary education	1	1	2
	Islamic/Quranic education only	0	2	2
	Tertiary education	0	1	1
Occupation	Trader	3	5	8
	Business owner	1	1	2
	No occupation	2	4	6
Age	Average age of husband (in years)	38	40
Age	Average age of mother-in-law	50 years	56 years

Community influencers included local religious leaders (6/16), traditional leaders or village heads (5/16), and community volunteers (5/16). Each community leader had completed either primary (4), secondary (4), or tertiary education (4), or the equivalent of Islamic/Quranic education (4). The average age of these community influencers was 54. See Table 5.

Table 5

Demographic breakdown of community influencers
Community Influencers (n = 16)
Characteristics		Local Government Area (LGA)		Total
Characteristics		Dukku (n = 5)	Yamaltu Deba (n = 11)	Total
Type	Community leader/village head	2	3	5
	Religious leader	2	4	6
	Community Volunteer	1	4	5
Highest education	No education	0	0	0
	Primary education	2	2	4
	Secondary education	1	3	4
	Islamic/Quranic education only	2	2	4
	Tertiary education	0	4	4
Age	Average age	54	54

The service providers interviewed included 5 PHC staff members (nurses, midwives, and clinicians) and 4 community volunteers known as Community Health Influencers and Promoters Service agents (CHIPS), who assist the community in accessing basic care at local PHCs. All CHIPS agents had secondary-level education, while PHC staff had tertiary-level education. The CHIPS agents had a minimum of 2 years of service experience, and PHC staff had at least 5 years of experience in primary healthcare service delivery. See Table 6.

Table 6

Demographic breakdown of service providers
Service Providers (n = 9)
Characteristics		Local Government Area (LGA)		Total
Characteristics		Dukku (n = 5)	Yamaltu Deba (n = 4)	Total
Type	CHIPS agents	2	2	4
Type	PHC service providers	3	2	5
Highest education	Secondary	3	2	5
	Tertiary	2	1	3
	Islamic education only	0	1	1
Service duration	0–5 years	2	3	5
	6–10 years	2	0	2
	11 years or more	1	1	2

The qualitative insights were categorised into supply-side and demand-side barriers to PHC maternal care uptake. Supply-side barriers are structural, influenced by the institutional level of the SEM model. Demand-side factors are rooted in individual, relational, and community levels, with the authors highlighting parallels to common psychological barriers.

Demand side-barriers

Awareness of PHC maternal care services

Most mothers were familiar with the concept of a PHC and the spectrum of services available at their local PHCs including ANC and FP. Those who knew what a PHC was, drew comparisons to "a small hospital" or identified it as a place to access ANC and child delivery services, immunisation, and treatment for malaria.

“Primary healthcare centres are where you get first healthcare before you go to bigger hospitals.” (Mother, 25, Yamaltu/Deba, Gombe State)

A majority of women and household decision-makers had basic understanding of FP and believed it was important for child spacing and reducing the risk of unwanted pregnancies, especially after birth.

"You will see a woman getting pregnant when her child is barely a year old and even lose the pregnancy at the end, so for these reasons, it [FP] is good and important." ( Mother, 45, Yamaltu/Deba, Gombe).

ANC awareness among women was more pronounced than FP awareness, with women reporting that they needed more information on FP services, particularly around long lasting contraceptives and how long injectable contraceptives last. The awareness and understanding of PHC maternal services was less prominent among women residing in the rural LGA (Dukku) compared to those in the peri-urban LGA (Yamaltu Deba).

Household decision-makers, particularly spouses, reported low levels of awareness regarding PHC maternal care services. Most were unfamiliar with the services offered and could not describe what antenatal care entails. Similar to the trends observed among mothers and expectant mothers, awareness among decision-makers was lower in the rural LGA compared to the peri-urban LGA.

"I am not sure of ANC services. I just know it's [PHC] like a small hospital for treatment of malaria, fever and blood tests." (Husband, 33, Yamaltu/Deba, Gombe).

This suggests that at the individual level (women) and relational level (household decision-makers), there are disparities in the awareness of PHC-based maternal services. These disparities in awareness could limit cohesive decision-making toward seeking maternal care.

Attitudes and beliefs toward PHC maternal care services

Despite the relatively good awareness among mothers of ANC and FP services, their attitudes toward uptake were mostly complacent, with little urgency around regular ANC. Attitudes were more curative than preventative, with infrequent ANC visits and general health-seeking at PHCs limited to emergencies like severe malaria. Few women reported giving birth at health facilities or consistently attending the recommended eight (8) ANC appointments during pregnancy. FP was seen as less of a priority than ANC and was not actively sought. Health-seeking at PHCs was often delayed until other forms of alternative care, such as self-medication through local or patent proprietary medicine vendors (PPMVs), had failed.

“Formal family planning is not a common thing in this area” (Traditional leader, 50, Dukku)

“All the women in my family gave birth at home and nothing happened to them, no ANC” (Husband, 41, Dukku)

Some women appeared to downplay the probability of experiencing maternal complications, exhibiting optimism bias regarding the necessity of preventative care like ANC. Optimism bias leads individuals to believe they are more likely to experience positive outcomes than negative ones [21]. This perception diminishes the perceived need for ANC and family planning at PHCs.

“If I feel there is any complication then I will go (for ANC) but thank God I do not think I need to” (Mother, 30, Yamaltu Deba).

The preference for curative over preventative healthcare may indicate a tendency to invest minimal effort in preventive care now, expecting to address health issues more intensively in the future if emergencies arise. This trade-off between present and future health-seeking behaviour reflects could be explained by present bias, where individuals prioritise immediate benefits over future ones [22]. In the context of our study, immediate benefits could be seen as the convenience of minimal health seeking effort in the present.

Additionally, community-held beliefs, often based on misinformation, influenced individual attitudes toward maternal health-seeking, particularly around FP. A prevalent misconception was that FP implants inserted into the vagina could disappear and destroy the womb.

"The method of FP is good, but I am scared because of the implant. Some said if inserted it won't come out and it causes bleeding, " (Expectant Mother, 27, Dukku, Gombe)

"There was this belief from our parents before we got married. They said anytime women went for ANC and were given drugs, the unborn child would grow so big in the womb of his mother, which must lead to an operation during delivery. “ (Husband, 40,Dukku, Gombe)

A few local beliefs were based on perceived religious narratives that contraceptive methods were against the will of God because it restricts the blessing of children.

“[FP] It’s not important, because God is the one who gives children and when to deliver them.” Expectant Mother, 23, Dukku, Gombe).

Household decision-making around maternal care

Although many women in the study understood the importance of ANC, more household decision-makers, compared to mothers and expectant mothers, were not fully aware of its purpose. This lack of awareness negatively impacted how maternal health-seeking was prioritised within the household. While some husbands mentioned accompanying their wives to at least one ANC visit, most only provided transportation and did not stay for the appointment or actively support regular ANC attendance, or inquire about family planning.

“I don’t really know what 'Antenatal Care Services' is... I know we used to have some women who came to this community advising our women to go for Antenatal care services.”(Husband, 50, Yamaltu/Deba, Gombe).

Alternatives to PHC-based maternal care

Community traditions and individual preferences for alternatives to PHC-based maternal care often normalised or worsened low health-seeking behaviour at PHCs. Home deliveries with traditional birth attendants (TBAs) were common, and TBAs, who are well-respected, sometimes foster scepticism about the effectiveness of formal ANC and distrust in PHC-prescribed maternal drugs and supplements. Additionally, nearly half of the women interviewed used traditional herbal methods for FP, such as herbal tinctures like pumpkin seeds.

"Traditional remedies are taken after sex then it goes in to melt the sperm so it doesn’t stay active, then another one it’s mixed with salt and kashin zomo [rabbit faeces]"(Expectant Mother, 27, Yamaltu/Deba, Gombe)

Widespread religious traditional practices were another layer to the community-level barriers to formal maternal care at a PHC. Some of the religious traditional practices included herbal remedies from Islamic medicine vendors for safe delivery or, relying on spiritual items such as beads for prevention of unwanted pregnancies and consuming liquids in which passages of the Quran to aid a healthy pregnancy.

“In my place, there is charm, or something tied on the waist which they remove whenever women want to get pregnant.”(Expectant Mother, 23, Dukku, Gombe).

“Arabic [from the Quran] written on slates, washed and given to women to drink has been used for healthy birth.” (Expectant Mother, 35, Dukku, Gombe).

"[For FP] there are local seeds of trees that they [traditional medicine vendors] mix and they also provide other Islamic medicine for women.” (Expectant Mother, 32, Yamaltu/Deba, Gombe).

Some traditional leaders acknowledged that traditional healthcare practices did hinder maternal health-seeking at a PHC. However, religion was not perceived as a significant barrier for most community members who were literate and well-informed on the importance of PHC-based care.

“For culture and traditional practices, I'll say yes. It hinders people from accessing the hospital as it promotes more of traditional medicine but religion doesn't really hinder anyone from accessing the hospital” (Community leader, 55, Dukku)

“Sometimes, people don’t believe in healthcare because of religion and illiteracy. But, with awareness we do convince religious people to seek care.” (Community leader, 62, Yamaltu Deba)

Supply-side barriers

All of the supply-side barriers were at the institutional level. These institutional-level barriers highlight the experiences of women in accessing PHC maternal services coupled with PHC service provider challenges in delivering quality maternal care.

Cost of maternal care and PHC proximity

The cost of PHC services was the most frequently cited barrier to regular ANC uptake. This cost burden included direct expenses (such as service fees and medication) and indirect costs (like transportation to and from the health facility).

“It is expensive, the amount is five hundred naira (per ANC visit) and some people don't go because of the price. They should reduce it to two hundred naira.” (Expectant Mother, 30, Dukku, Gombe).

Transportation costs were a major issue for Dukku residents due to its larger size and fewer functional PHCs (17) than Yamaltu Deba. The average distance to the nearest PHC in Dukku was greater, with the farthest being 40 to 60 minutes away by commercial motorcycle. While ANC visit fees ranged from NGN 1,000 to NGN2,000, which is relatively affordable, some respondents reported additional 'under-the-table' payments to avoid delays, causing care costs to vary. These transportation and unpredictable costs discouraged consistent health-seeking, particularly among those with lower household incomes.

Quality of care and availability of medical resources

A major institutional barrier to seeking ANC and FP services at PHCs was the poor quality of care, primarily due to limited resources and staff shortages. Despite Dukku's population of over 207,000 as of the 2006 census, there were only 17 functional PHCs, each potentially serving over 5,000 people during the implementation of this study. This strain on resources led to long wait times for ANC appointments and complaints from women about insufficient staff. Additionally, shortages of beds, essential ANC commodities like folic acid and iron supplements, and poorly maintained equipment, such as sonographic scanners, further compromised care quality.

“My experience was not encouraging, because they kept us waiting for a long time unattended, and I was very hungry by then. I promised not to go back to the hospital because they did not treat us well and did not give us anything.” (Expectant Mother, 23, Dukku, Gombe)

In Dukku LGA, concerns about healthcare worker absenteeism and limited accessibility of commodities were more pronounced. Absenteeism among maternal care providers in these areas exacerbated the pressure on already overburdened staff.

"Sometimes they don’t attend to people in time and also refer to some patients as dirty people. You sometimes feel like never visiting the PHC again.” (Expectant Mother, 35, Dukku, Gombe)

Capacity of service providers

Despite the relatively extensive professional experience of the healthcare providers interviewed, many noted that their training consisted mostly of technical skills (e.g., BP measurement, child growth tracking) and lacked soft skills like bedside manner, interpersonal skills, and patient empathy, leaving them unprepared for empathetic patient interactions.

"We could benefit from better pay, training on how to handle high-pressure scenarios, and how to deal with difficult patients. How to manage patients". (Service provider, Dukku)

“Stop shouting at patients because no one visits the PHC for fun but for medication. If not for persistent pains or ailments, some women wouldn't have gone back to the PHC again". (Expectant Mother, 35, Dukku, Gombe)

The lack of interpersonal skills, combined with overworked and often underpaid staff, led to harsh and unempathetic care. This lack of empathy discouraged some women from returning to PHCs and adhering to recommended ANC visit schedules.

The synthesis of the qualitative findings with the aid of the SEM model revealed supply-side and demand-side barriers to utilisation of ANC and FP at a PHC. The supply-side constraints can be viewed as structural barriers beyond the control of PHC service end-users (women and their households) that are largely driven by institutional-level factors that limit the quality of care available. The demand-side barriers are mostly characterised by individual, relational and community-level factors that consist of awareness, beliefs, perceptions, community norms and practices that shape decision-making in accessing maternal care.

Supply-side barriers

The cost of maternal services at a PHC is among one of the leading causes of maternal care neglect expressed by women in the study sample. Similar studies show costs stand as a barrier to initial uptake of maternal care especially among rural households across Sub-Saharan Africa (SSA) [23, 24]. Proximity and the cost of transportation go hand in hand and pose a considerable disadvantage, particularly during off-peak times when public transportation is unavailable in remote locations [25].

Costs may hinder initial engagement with PHC-based maternal care services, but poor PHC service quality and delivery discourage continued or repeat usage of maternal services [23, 25]. The concerns with maternal care quality hinged on 3 factors; service attitude, service delivery promptness and PHC resources. The lack of PHC resources such as tools for sonography, maternal supplements, beds, etc are often remedied easily with injections of more state-level funding, however, the supply of trained health personnel and behaviour change in service attitudes are often more difficult to achieve because it requires both health system investments and behaviour change interventions [26]. Poor service delivery attitudes are often due to inadequate training on soft skills around patient care and staff shortages which strain existing human resources and make it difficult to provide patient and attentive care [12, 26–28]. Assessments of healthcare service quality in Nigeria [29] and South Africa [30] also suggest the absence of disciplinary actions for poor service attitudes and poor supportive supervision create a culture around negligent patient care. Interventions that encourage and reward service delivery performance have been found to incentivize better quality care [31].

Demand-side barriers

The demand-side barriers reflected some common cognitive or behavioural barriers to maternal service uptake for ANC and FP that appear across behavioural science literature. These cognitive barriers are rooted in the beliefs, practices and perceptions reported by mother/expectant mothers and household decision-makers that relate to individual, relational and community-level factors.

Optimism Bias

The qualitative insights reveal that while awareness of ANC and FP services at PHCs is generally good, some women exhibit inconsistent or low engagement with these services. This complacency may be attributed to optimism bias, a cognitive distortion where individuals underestimate their risk of adverse outcomes [32]. Perceived risk is a key determinant of engagement in preventive health-seeking behaviour and optimism bias has been linked to delays in preventive health measures for other contexts, such as COVID-19 [33], cancer and sexual health screening [34, 35]. In this study, some women’s lack of urgency toward preventive maternal care appears to stem from an overly positive view of their health, likely influenced by past risk-free experiences that did not involve PHC-based care.

Overconfidence Bias

This study highlights a preference for alternative maternal care, such as consulting traditional birth attendants and using herbal or religious remedies, which aligns with existing literature [10, 11, 12]. These preferences are influenced by community traditions and cultural practices, as well as an overconfidence bias [36] in their ability to manage health independently without the aid of formal PHCs. Some households exhibited excessive confidence in their self-efficacy, relying on traditional remedies without professional medical consultation around maternal risks. Overconfidence bias is more widely studied in the context of service provider errors in diagnostics and quality of care [37], however, a growing body of research shows it can be linked to health-seeking behaviour [38]. Research from Northern Nigeria and East Africa suggests that a lack of perceived control or low locus of control over health and believing it to be governed by higher powers—can also deter formal healthcare use [39]. Further research is needed to explore the extent to which overconfidence and locus of control affect maternal health-seeking behaviour.

Present Bias

Financial and time costs delaying preventative maternal care at PHCs were a key institutional-level factor identified in this study and similar research across SSA and Asia [10, 11, 12]. This delay can be viewed through the lens of present bias, where immediate costs are prioritised over future benefits [40]. Present bias has been proven to adversely influence financial behaviours in low-income demographics [40]. In the context of this study, present-biased households may perceive current costs of ANC and FP as higher than future costs related to unplanned pregnancies or birth complications [41]. This bias can negatively impact how households prioritise health-seeking in the present and long-term maternal and child health outcomes.

Salience Bias

A key theme in this study is the lack of salience. Salience can be understood as the perceived importance placed on knowledge and information. Despite general awareness of ANC and FP, perceived importance is often overshadowed by conflicting traditions and existing alternative health practices. Misinformation and limited salience among household decision-makers, such as husbands, further diminish the perceived urgency of ANC services. Studies show salience and social influence significantly affect health behaviours, including maternal care uptake [23, 25, 42, 43]. Enhancing salience through targeted advocacy and addressing misinformation could improve maternal care uptake. Highlighting the potential losses from neglecting maternal care could also create a greater sense of urgency [42].

Although demand-side factors largely drive the barriers to maternal care, supply-side issues also play a significant role in limiting demand. Poor service delivery at PHCs contributes to negative perceptions about the care quality, which are then communicated through interpersonal and community networks [22, 24, 44]. This highlights the need for behaviour change interventions at the individual and interpersonal levels and institutional reforms to improve care quality. Institutional efforts, such as developing quality care guidelines, implementing supportive supervision, and introducing conditional cash transfers, are examples of institutional-level interventions that aim to ease access and availability of quality care [45, 46]. However, achieving lasting behaviour change at both institutional and individual levels requires time and sustained efforts to form new habits.

Areas for further research

This study explores the structural (supply side) and cognitive (demand side) barriers around ANC and FP uptake. Addressing these barriers and creating new health-seeking habits, although possible, can be quite challenging especially if preferences are sticky [40]. Further research could investigate the levers and interventions that could ease these barriers.

Study limitations

The main limitation of this study was the low diversity in the cadre of maternal care service providers interviewed. This limited the variation in service provider experiences captured and institutional-level barriers identified.

This study adds a unique perspective to current research around barriers to maternal care by mapping SEM-based demand-side and supply-side barriers and highlighting the behavioural/cognitive biases that exemplify the demand-side challenges identified. The study application of the SEM model provides a holistic approach to synthesising qualitative data to unpack factors across all levels of society that affect the decision to seek maternal care at a PHC. The findings show most barriers are rooted in individual, and relational, followed by community-level factors that revolve around knowledge and awareness of ANC and FP, perceptions of PHCs, and traditional and cultural beliefs around maternal care. Similarly, although fewer barriers such as cost and quality of care are rooted at the institutional level, they have far-reaching impacts on demand-side health-seeking behaviours.

Acknowledgments

The authors acknowledge the vital contributions of the consortium partners—The National Primary Health Care Development Agency (NPHCDA), Solina Centre for International Development and Research (SCIDaR), and The Center for Communications and Social Impact (CCSI)—whose support was instrumental in the success of this project and the production of this important work.

Authors Contribution

M.M.A. contributed to the conception of the study design, acquired and interpreted the data, and revised the work. M.A.Y. contributed to the study design, data acquisition, analysis, interpretation, and drafting. R.N. contributed to the analysis, interpretation, and revision. A.O. contributed to data acquisition, analysis, and interpretation. F.M. helped conceive the study design and revised the work. J.S. substantively revised the work. Z.H.S., Y.O., and Z.I.I. contributed to the conception, study design, data acquisition, and interpretation. M.A. and A.I.U. contributed to the study design, data acquisition, and interpretation. L.U. contributed to the conception and study design. All authors read and approved the manuscript for publication.

Competing interests

There are no competing interests among all contributing authors.

Funding

The study received funding from the Bill & Melinda Gates Foundation.

Ethics approval and consent

Ethical approval for the study was obtained from the Nigerian National Health Research Health Committee of Nigeria (NHREC) and given an assigned number of HREC: NHREC/01/01/2007 on March 21, 2022. Written and verbal informed consent was obtained individually from all participants by the study field team. Participants with low literacy provided verbal consent.

Availability of data and materials

The datasets generated and analysed during this study are not publicly available due to the privacy clause stipulated in participant consent. The qualitative tools used are available upon request from the corresponding author.

Consent for Publication

All authors and supporting authors consent to the publication of this study. Consent forms of all authors will be made available upon request.

Samuel O, Zewotir T, North D. Decomposing the urban–rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in sub-Saharan Africa. Reprod Health 18, 216. 2021.
Olamijulo J, Olorunfemi G, Okunola H. Trends and causes of maternal death at the Lagos University teaching hospital, Lagos, Nigeria (2007–2019). BMC Pregnancy Childbirth. 2022;22(1):360. doi:10.1186/s12884-022-04649-4
Leitao S, Manning E, Greene RA, Corcoran P. Maternal morbidity and mortality: an iceberg phenomenon. The Maternal Morbidity Advisory Group. First published: 28 August 2021 https://doi.org/10.1111/1471-0528.16880
World Health Organization (WHO). Maternal mortality: The urgency of a systemic and multisectoral approach in mitigating maternal deaths in Africa. Published 2023. https://files.aho.afro.who.int/afahobckpcontainer/production/files/iAHO_Maternal_Mortality_Regional_Factsheet.pdf
Geller SE, Koch AR, Garland CE. et al. A global view of severe maternal morbidity: moving beyond maternal mortality. Reprod Health 15 (Suppl 1), 98. 2018. https://doi.org/10.1186/s12978-018-0527-2
Miller, S., Belizán, J.M. The true cost of maternal death: individual tragedy impacts family, community and nations. Reprod Health 12, 56. 2015.
Smith J, Banay R, Zimmerman E, Caetano V. Musheke M, & Kamanga A. Barriers to provision of respectful maternity care in Zambia: results from a qualitative study through the lens of behavioural science. BMC Pregnancy and Childbirth, 20(1). 2020; doi:10.1186/s12884-019-2579-x
Jolivet RR, Moran AC, O’Connor M. et al. Ending preventable maternal mortality: phase II of a multi-step process to develop a monitoring framework, 2016–2030. BMC Pregnancy Childbirth 18, 258. 2018. https://doi.org/10.1186/s12884-018-1763-8
Hanefeld J, Powell-Jackson T, Balabanova D. Understanding and measuring quality of care: Dealing with complexity. Bull World Health Organ. 2017; 95:368-374. doi:10.2471/BLT.16.179309
Ope BW. Reducing maternal mortality in Nigeria: addressing maternal health services’ perception and experience. Journal of Global Health Reports. 2020;4:e. doi:10.29392/001c.12733
Meh C, Thind A, Ryan B. et al. Levels and determinants of maternal mortality in northern and southern Nigeria. BMC Pregnancy Childbirth 19, 417. 2019. https://doi.org/10.1186/s12884-019-2471-8
Sarikhani, Y, Najibi SM & Razavi Z. Key barriers to the provision and utilisation of maternal health services in low-and lower-middle-income countries; a scoping review. BMC Women's Health 24, 325 (2024).
Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7):513–531. [Google Scholar]
McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77. https://doi.org/10.1177/109019818801500401.
Bell, Lartey B, Spickernell G, Darrell N, Salt F, Gardner C, et al. Applying a social-ecological model to understand factors impacting demand for childhood vaccinations in Nigeria, Uganda, and Guinea, SSM - Qualitative Research in Health, Volume 2, 2022, 100180.
Olaniyan, A, Isiguzo C. & Hawk M. The Socioecological Model as a framework for exploring factors influencing childhood immunisation uptake in Lagos state, Nigeria. BMC Public Health 21, 867. 2021. https://doi.org/10.1186/s12889-021-10922-6
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–357. doi: 10.1093/intqhc/mzm042.
Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. 2022; doi: 10.1016/j.socscimed.2021.
Wada YH, Musa SS, Musa SK, Musa MK, Bakabe TI, Abdullahi AK, Ahmadi A, Lucero-Prisno DE. COVID-19 and insecurity in Northern Nigeria. Disaster Med Public Health Prep. 2022 Mar 31:1-7. doi: 10.1017/dmp.2022.81.
Braun V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi: 10.1191/1478088706qp063oa
Bracha A, Brown DJ. Affective decision making: A theory of optimism bias, Games and Economic Behavior, Volume 75, Issue 1. 2012. Pages 67-80, ISSN 0899-8256, https://doi.org/10.1016/j.geb.2011.11.004.
Wang Y, Sloan FA. Present bias and health. J Risk Uncertain. 2018 Oct;57(2):177-198. doi: 10.1007/s11166-018-9289-z. Epub 2018 Oct 25. PMID: 31244508; PMCID: PMC6594564.
Dahab R, Sakellariou D. Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review. Int J Environ Res Public Health. 2020 Jun 16;17(12):4292. doi: 10.3390/ijerph17124292. PMID: 32560132; PMCID: PMC7344902.
Kowalewski M, Mujinja P, & Jahn A. Can Mothers Afford Maternal Health Care Costs? User Costs of Maternity Services in Rural Tanzania. African Journal of Reproductive Health, 6(1), 65. 2002; doi:10.2307/3583147
Arnold J, Samson M, Schechter J, Goodwin AS, Braganza S, Sesso G.C, Lopez A, Fiori K. Getting there: Overcoming barriers to reproductive and maternal health services access in Northern Togo: A qualitative study. World Med. Health Policy. 2016;8:223–244. doi: 10.1002/wmh3.195.
Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Global Health. 2015. doi: 10.1186/s12992-015-0117-9. PMID: 26276053; PMCID: PMC4537564.
Afsana K, Rashid SF. The challenges of meeting rural Bangladeshi women's needs in delivery care. Reprod Health Matters. 2001;9(18):79–89.
Bowser D, Hill K. Exploring Evidence for Disrespect and Abuse in facility-Based Childbirth: Report of a Landscape Analysis. USAID; 2010.
Akin-Otiko BO, Bhengu BR. Client education experiences and expectations of women at the first level of maternal and child care in Kaduna state. Niger Midwifery. 2012;28(6):e893–9.
Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Soc Sci Med. 1998;47(11):1781–95.
Abduljawad A, Al-Assaf AF. Incentives for better performance in health care. Sultan Qaboos Univ Med J. 2011 May;11(2):201-6. Epub 2011 May 15. PMID: 21969891; PMCID: PMC3121024.
Nezlek, J. B., and B. D. Zebrowski. 2001. Implications of the dimensionality of unrealistic optimism for the study of perceived health risks. Journal of Social and Clinical Psychology, 20(4), 521-537.
Park T, Ju I, Ohs JE, Hinsley A. Optimistic bias and preventive behavioural engagement in the context of COVID-19. Res Social Adm Pharm. 2021 Jan;17(1):1859-1866. doi: 10.1016/j.sapharm.2020.06.004.
Fontaine KR, Smith S. Optimistic bias in cancer risk perception: a cross-national study. Psychol Rep. 1995;77:143–146.
Wiebe DJ, Black DElusional beliefs in the context of risky sexual behaviours 1. Journal of Applied Social Psychology. 1997;27:1727–1749.
Johnson DD, Fowler JH. The evolution of overconfidence. Nature. 2011 Sep 14;477(7364):317-20. doi: 10.1038/nature10384. PMID: 21921915.
Roxanne J. Kovacs, ML, Cairns J. Overconfident health workers provide lower quality healthcare. Journal of Economic Psychology. Volume 76. 2020,102213,ISSN 0167-4870, https://doi.org/10.1016/j.joep.2019.102213.
Arni P, Dragone D, Goette L. Ziebarth NR. Biased health perceptions and risky health behaviours—Theory and evidence. Journal of Health Economics, Volume 76. 2021, 102425, ISSN 0167-6296, https://doi.org/10.1016/j.jhealeco.2021.102425.
Akin-Otiko BO, Bhengu BR. Client education experiences and expectations of women at the first level of maternal and child care in Kaduna state. Niger Midwifery. 2012;28(6):e893–9.
Ashton L, Giridhar N, Holcombe SJ, Madon T, Turner E. A review of behavioural economics in reproductive Health. Centre for Effective Global Action (CEGA). 2015.
Curtis AK, and Croft TN. Monitoring contraceptive continuation: links to fertility outcomes and quality of care-Studies in Family Planning, 2002, 33(2):127–140.
Abdulai MA, Marable JK, Wadus A, Asante KP. A qualitative analysis of factors influencing health-seeking behaviour of people living with HIV, hypertension and diabetes in an urban area of Ghana. Journal of Multimorbidity and Comorbidity. 2022;12. doi:10.1177/26335565221092664.
Taylor SE, Fiske ST. Salience, attention, and attribution: Top of the head phenomena. In: Advances in Experimental Social Psychology. 1978;11:249- 288. https://doi.org/10.1016/S0065-2601(08)60009-X 23. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77 –101.
Thongmixay S, Essink DR, Greeuw TD, et al. Perceived barriers in accessing sexual and reproductive health services for youth in Lao People’s Democratic Republic. PLoS One. 2019;14(10):e0218296. doi: 10.1371/journal.pone.0218296.
Udenigwe O, Okonofua F.E, Ntoimo LFC, et al. Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria. BMC Pregnancy Childbirth 21, 20. 2021. https://doi.org/10.1186/s12884-020-03493-8https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03493-8.
Okoli U, Morris L, Oshin A, Pate MA, Aigbe C, Muhammad A. Conditional cash transfer schemes in Nigeria: potential gains for maternal and child health service uptake in a national pilot programme. BMC Pregnancy Childbirth. 2014;14(408):1-13. Available from: https://doi.org/10.1186/s12884-014-0408-9.

No competing interests reported.

Download PDF

Reviewers agreed at journal
15 Aug, 2024
Reviewers agreed at journal
12 Aug, 2024
Reviewers invited by journal
12 Aug, 2024
Editor invited by journal
06 Aug, 2024
Editor assigned by journal
04 Aug, 2024
Submission checks completed at journal
04 Aug, 2024
First submitted to journal
02 Aug, 2024

You are reading this latest preprint version

Supply and Demand Barriers to PHC Maternal Care Services Uptake: Qualitative and Behavioral Insights from Gombe State, Nigeria

Status:

Version 1

Abstract

Background

Materials and Methods

Study design

Study sample

Data collection and questionnaires

Study location

Data Analysis

Results

Participant description

Household decision-making around maternal care

Alternatives to PHC-based maternal care

Cost of maternal care and PHC proximity

Quality of care and availability of medical resources

Capacity of service providers

Discussion

Optimism Bias

Overconfidence Bias

Present Bias

Salience Bias

Conclusion

Declarations

Ethics approval and consent

References

Additional Declarations

Status:

Version 1