Gender, age, and marital status should not affect the right to receive high-quality, gender-sensitive, and respectful services when seeking ANC and L&D care or other health services, such as family planning. Yet gender norms embedded in sociocultural practices persist, and drive providers’ poor attitudes, perpetuate violence, limit the utilization of facility-based services, and contribute to poor RMNCAH outcomes [5, 6]. The current findings have implications for designing interventions to help improve the provision of gender-sensitive and respective care: program planners must be intentional about addressing and measuring inequalities, as well as improving quality, respectful care.
Beliefs and perceptions
Nighty-eight percent of providers believed that it was appropriate and important for a man to participate in RMNCAH services and support his female partner. This is consistent with previous findings from hospitals in Nigeria where midwives acknowledged the benefits of having a partner present, for example, contributing to pain relief during childbirth [49]. Previous studies have found that engaging men in reproductive, maternal, and newborn health can increase care seeking, improve home care practices, and support more equitable communication and decision-making among couples related to maternal and newborn health [1, 27]. Despite this recognition, facilities did not have adequate privacy in the L&D and postpartum wards to enable men to attend L&D and did not allow or encourage men to participate.
However, as a reflection of gender norms that prioritize men’s power in decision-making, most providers did not think women should have autonomy in FP decision-making—67.6% of providers interviewed in Ebonyi State and 50.7% in Kogi State believed that a woman should not choose a FP method on her own. Even though multiple studies have shown FP to be generally accepted as women’s responsibility [50], in Kogi and Ebonyi States, providers believed the decision of whether or not to use FP should be made by the man or by the couple together, and the woman should be responsible for implementing FP decisions. A previous study in Nigeria found that men often think that women should take responsibility for using contraception, but that men should control the decision-making [51]. These perspectives may be at odds with current programs in Nigeria that direct FP awareness raising toward women alone, excluding men, given that Nigerian couples often do not discuss FP [52] and that men typically do not participate in FP consultations.
Providers also held discriminatory beliefs about who should be allowed to use FP. Beliefs were based on culture, gender, and religion rather than medical need or client preference. According to the Demographic and Health Survey, “Women and men in Nigeria tend to initiate sexual activity before marriage.” Approximately one-third of women in Ebonyi and in Kogi had sex before the age of 18, but the median age of marriage for women in Nigeria was 18.1 [1]. Our study found that 23.2% of providers did not think unmarried clients should use FP services. A study in Ibadan, Oyo State, Nigeria, found that 57.5% of providers believed that unmarried adolescents should be told to abstain from sex rather than be provided with contraceptives, which they believed would promote sexual promiscuity. Providers also believed that contraceptives should not be provided to adolescents, whether married or unmarried [53]. Another program in Nigeria found that providers turned away unmarried clients, newly married couples, or couples with only one baby from FP services based on personal beliefs that unmarried clients should not be having sex and that newly married couples should begin childbearing right away to produce large families [20].
Practices, roles, and participation
As in many health settings globally, we found that the majority of health providers were female, but the majority of supervisors were male [10, 41]. This relative exclusion of women from equitable leadership positions could be due to a number of factors, including discriminatory attitudes about women’s ability to be managers, a lack of gender-sensitive workplace policies such as breastfeeding rooms and parental leave, and sexual harassment and violence. These factors have been shown to lead to burnout, attrition, mistreatment of patients, and the delivery of poor quality health services [10].
Birth preparedness counseling observed during ANC consultations revealed low levels of interaction and engagement between providers and clients. Women were inadequately informed about the status of their pregnancy and their options for childbirth, which may reflect providers’ bias about women’s agency and dignity.
Over one-third of respondents reported having experienced, observed, or heard of at least one incident of violence or mistreatment against clients. This included being yelled at, threatened, or ignored by facility staff and, in a minority of cases, being punched, kicked, dragged, or beaten.
Mistreatment of women in labor is common in many RMNCAH service delivery settings [6]. Our study observed no occurrence of slapping, hitting, or pinching clients during or after labor in either state. However, potentially harmful practices were observed. For example, routine episiotomies that are not required (and put women at risk of harm, infection, and sepsis) signify acts of mistreatment [54]. Our findings are consistent with an earlier study that found women’s perception of quality of care was lowest related to privacy and respect for clients [55].
Institutions, laws, and policies
Enhancing privacy during care was a gender-based constraint to accessing high-quality RMNCAH care. Our study found that only 36% of facilities were equipped to accommodate male birth companions due to limited privacy. Despite the recognition that engaging men in maternal and newborn health is beneficial [1, 27], even if men wanted to accompany their wives, facilities were unequipped to allow men to do so while maintaining the privacy of other clients.
Study strengths and limitations
This was a small-scale cross-sectional study that included direct observation of antenatal and labor and delivery care, the gold standard for understanding quality of care; and interviews with health care providers to inform programmatic activities that strengthen the quality of RMNCAH service delivery. Observations were limited to ANC consultations and and births that occurred on the days data collectors were present. The final number of L&D observations was small due to low caseloads therefore the margins of error are wide. However, the study was not designed to be representative of the entire country but to provide baseline data within the two states to inform local project design. Given that health service providers across Nigeria operate under similar conditions and that the gender norms present in our study exist throughout Nigeria, we believe that the findings of this gender analysis can effectively inform gender integration for maternal and newborn health programming across the country.
Providers may have delivered care differently because they were under observation (Hawthorne effect), resulting in underreporting of gender discrimination or mistreatment in care. Social desirability bias may have impacted providers’ interview responses.
Another limitation of the study stems from the sensitivity towards terms such as gender, gender-based violence, disrespect and abuse, or mistreatment among providers in Nigeria. These terms were included in the survey instruments and potentially affected responses from providers because these terms may have elicited negative reactions, particularly for questions regarding workplace gender dynamics. Widespread conflation of the term “gender” with women’s issues—which are often dismissed as a western imposition, a modern fad, an attack on men’s rights, an attack on tradition/culture/religion, or an accusation that all men are bad—may have influenced respondents interpretations of the term. Some respondents may have not understood what was meant by gender within the study. Additionally, some types of violence may not have been considered violent by respondents due to the high acceptance of violence against women and the culture of silence surrounding gender-based violence in Nigerian society. Further validation of the study tools would have helped to limit misinterpretation.
Recommendations
Gender-discriminatory beliefs and practices identified in our study hold far-reaching implications for the ability of women to make self-directed decisions about RMNCAH. Gender-discrimination negatively impacts the ability of providers to deliver gender-sensitive care that respects women’s human rights, dignity, and bodily autonomy [20]. For RMNCAH programming in Nigeria to be successful, programs must meaningfully engage men, women, and community leaders in awareness raising, in ways that respect women’s reproductive autonomy, agency and rights. And efforts must go beyond just the benefits of healthy timing and spacing of pregnancies and limiting family size. Capacity building of providers, as well as health facility’s and national policies, should reinforce that health service delivery should not be influenced by morals, gender biases, or religion, but should focus on medical needs, client preferences, and evidence-based approaches to care.
Our findings indicate an opportunity to improve reproductive health outcomes and leverage couples counseling to mitigate power imbalances between men and women around fertility and encourage women to participate in joint decision-making. In order to transform perceptions of RMNCAH services from being solely a woman’s issue to a joint endeavor between couples [31], previous studies [12, 56] recommended the creation of a supportive and male-friendly environment at health facilities that encourages men to be involved in maternal health services [19]. Further interventions are therefore needed at the institutional level to ensure that men are able to accompany their partners to L&D, including creating private L&D and postpartum spaces within health facilities, sensitization, training and guidance for health providers on how to engage men along the RMNCH continuum.
Such capacity building, guided by a 2018 gender capacity building framework for providers [57], can improve providers’ ability to counsel men and couples and advocate for facility preparedness to engage men in pregnancy and childbirth (when women desire men’s presence). Such efforts, however, must ensure that attempts to engage men do not infringe upon women’s reproductive autonomy by encouraging men to take control of reproductive health decision-making. Instead, they should increase and uphold women’s agency, self-efficacy, and decision-making power.
Health providers were identified as having a key role in changing the negative effects of harmful gender norms and stereotypes by empowering both women and men to make informed choices about their health. A study on improving reproductive health outcomes, Stover et al. highlighted the importance of creating opportunities for providers to clarify personal values and offer services in a nonjudgmental way to meet clients’ reproductive health needs [58].
There are not many RMNCAH interventions which address gender as a determinant of mistreatment during maternal and newborn health care [10]. Interventions include provider trainings to clarify values and transform attitudes in order to facilitate understanding of gender-discriminatory behaviors and attitudes, which influence mistreatment during labor and childbirth (for example, the WHO Health Workers for Change quality of care curriculum [59] and the Jhpiego Gender Transformation for Health Toolkit) [60]. These can be part of wider efforts to engage policymakers to focus on mistreatment during labor and childbirth and to support accountability by strengthening community and health facility linkages, putting in place systems to gather patient complaints and feedback and developing patient charters at the facility level [10]. Interventions that support a positive work environment for health providers are also needed. For example, the Heshima Project in Kenya worked at the community, facility and policy levels to examine the extent and causes of mistreatment in care in Kenya, and designed and implemented interventions to promote respectful care [61]. MCSP provided recommendations to the Nigerian MOH including a scale up of the Health Workers for Change Curriculum; capacity building and ongoing mentorship on gender-sensitive service delivery, male engagement and couples’ counseling; and first-line support to survivors of GBV. MCSP also recommended a scale up of efforts to improve infrastructure for privacy in L&D and post-natal wards in health facilities.