Detecting and managing hypertensive disorders in pregnancy: a cross-sectional analysis of the quality of antenatal care in Nigeria

Abstract

Background: Nigeria has one of the highest rates of maternal mortality in the world (576/100,000 births), with a significant proportion of death attributed to hypertensive disorders in pregnancy (HDPs). High quality antenatal care (ANC) plays a crucial role in early detection and management of HDPs. We conducted an assessment of quality of antenatal care, and its capacity to detect and manage HDPs, in two tiers of Nigerian facilities, with the aim of describing the state of service delivery and identifying the most urgent gaps.

Methods: Quality of antenatal care was assessed and compared between primary healthcare centers (PHCs) (n = 56) and hospitals (secondary + tertiary facilities, n = 39) in seven states of Nigeria. A cross-sectional design captured quality of care using facility inventory checklists, semi-structured interviews with healthcare providers and clients, and observations of ANC consultations. A quality of care framework and scoring system was established based on aspects of structure, process, and outcome. Average scores were compared using independent sample t-tests and measures of effect were assessed by multivariate linear regression.

Results: All domains of quality except provider interpersonal skills scored below 55%. The lowest overall scores were observed in provider knowledge (49.9%) and provider technical skill (47.7%). PHCs performed significantly worse than hospitals in all elements of quality except for provider interpersonal skills. Provider knowledge was significantly associated with their level of designation (i.e., obstetrician vs. other providers).

Conclusions: In order to provide high quality care, ANC in Nigeria must experience massive improvements to inventory, infrastructure and provider knowledge and training. In particular, ANC programs in PHCs must be revitalized to minimize the disparity in quality of care provided between PHCs and hospitals. The relatively low quality of care observed may be contributing to Nigeria's high rate of maternal mortality and burden of disease attributed to HDPs.

Keywords: Antenatal care - maternal health - quality of care - health systems; Hypertensive disorders in pregnancy - primary health care.

Fig. 1

Map of study sites. Data was collected from 95 participating hospitals in 7 states across the 6 geopolitical zones of Nigeria. Geopolitical zones are divided based on similarity in culture, ethnic group, and common history. Including all hospitals from all geopolitical zones helps to ensure representative national results. Rights to this image are owned by the author

Fig. 2

Comparison of domains of quality of care across facility type. All domains except for interpersonal skills obtained a cumulative score of below 55%. The lowest overall scores were obtained in provider and provider skill (47%) and provider training/knowledge (49%), while the highest scores were obtained in provider interpersonal skills (85%). PHCs scored lower than hospitals in all domains except provider interpersonal skills

Fig. 3

Linear regression coefficients examining provider knowledge score. Each row represents a variable included in the multivariable linear regression assessing factors associated provider knowledge scores. After adjustment for provider sociodemographic factors, the level of facility (primary vs. secondary) was no longer significant. Compared to obstetricians/gynecologists (reference group), each of the other provider types (general practitioner, nurse/midwife, CHEW, and CHO) obtained significantly lower knowledge scores