Of the 21 sub-Saharan African Global Plan priority countries, Nigeria has had the lowest PMTCT coverage rates and highest PMTCT service delivery gap. With approximately 190 000 HIV+ women giving birth yearly in Nigeria [
Poor or no ANC and PMTCT care impacts on maternal and infant outcomes such as maternal mortality, infant mortality, and MTCT. In Nigeria, there are over 7 million live births annually [
Low rates of maternal health service utilization in sub-Saharan Africa (SSA) have been linked to women’s socioeconomic dependency on men, and unequal gender relations arising from religious and cultural influences [
As of 2015, Nigeria has a population of over 182 million people [
Maternal health outcomes also portray staggering North-South differences. The national Maternal Mortality Ratio (MMR) is 560 per 100,000 live births compared to the global average of 210 per 100,000 [
There is a paucity of literature from Nigeria and other SSA countries on associations between religious beliefs and uptake of maternal health services among Christian women. An Ethiopian study reported that orthodox Christians do rely on their spirituality and faith-based practices in health-seeking behavior and in coping with illness [
The extent to which religious law or teachings influence health-seeking behavior might differ between and within countries. For example, in the Middle East and North Africa, a Muslim woman is required to have her husband or a male relative to accompany her outside the home [
A few studies have investigated faith-based influences on healthcare utilization among Muslim Nigerian women. Previous studies in Northern Nigeria described faith-related factors that were barriers to Muslim women’s use of maternal health services: having to obtain permission from significant others [
The venues for this qualitative study were one urban community and 6 periurban and rural Primary Healthcare Centers (PHCs) located in the Federal Capital Territory (FCT) and Nasarawa State in North-Central Nigeria. The 6 sites were selected from a list of 26 study-eligible PHCs assessed for a large implementation research study conducted in rural and hard-to-reach areas of the aforementioned states (see Section
Study population included pregnant ANC attendees, HIV-positive women, and young women of childbearing age. Focus Group Discussions (FGDs) were conducted as part of the MoMent Nigeria study, a Canadian government-funded and World Health Organization-supported PMTCT implementation research project under the 6-study, 3-country INSPIRE initiative [
Ethical approval was granted by the Institutional Review Boards of the Institute of Human Virology Nigeria and the University of Maryland, Baltimore.
Two FGDs were conducted among Mentor Mothers, 2 among pregnant ANC clinic attendees, 2 among mother-to-mother (M2M) HIV support group members, and 1 with young women, totaling 7 FGDs. An interviewer-administered form was used to capture participants’ sociodemographic information such as religious affiliation, age, place of residence, marital status, and parity. Religious affiliation data was collected only after consent was provided and as such the focus groups were a mixture of both Muslim and Christian women. The FGDs were guided by semistructured questionnaires organized thematically as follows: barriers to uptake of ANC services (cost, distance, quality of ANC service, and attitude of healthcare providers), women’s views and experiences as members of M2M groups, and/or being Mentor Mothers, use of unconventional healthcare services or remedies, stigma related to HIV+ status, gender preference for a healthcare provider, and acceptability of Mentor Mother services. FGD facilitators comprised two Social Science professors as well as health professionals (doctors, nurses) and graduate students trained to conduct FGDs. A moderator and comoderator facilitated all FGDs along with at least one observer documenting synergistic group effects and nonverbal cues. Sessions were conducted in English and/or Hausa (the dominant language of the study communities). Bilingual (English and Hausa) facilitators were involved in the conduct, transcription, and analysis of all the FGDs. To maintain anonymity and establish a conducive atmosphere for discussion, participants used self-chosen aliases for each FGD. Each FGD was audio-recorded and lasted approximately 60–90 minutes.
Audio recordings were transcribed verbatim; Hausa sessions were transcribed into English by bilingual study staff. FGD transcripts were assigned to 4 groups of 2 coders each. Coders were the same trained individuals who facilitated and transcribed the FGDs. Each group member independently hand-coded their assigned transcript by reviewing each line, phrase, and paragraph to identify the initial key themes. Subsequently, each coding group met separately and then with all other groups, for review and merging of independently analyzed and coded transcripts into a final document. This stage was succeeded with a joint review of each of the 5 groups’ finalized transcripts by the entire team (a panel of 10 researchers from the 4 groups, facilitated by two Social Science professors). In this validation process, codes and themes were examined for content within the context of the document and thematically in relation to the overall interview guide. The resultant data were combined into one matrix to develop visual charts of the words and phrases that represented the themes discovered during analysis. In order to protect the privacy of the respondents and organizations, names of persons and institutions were deleted in the final report.
A total of 68 women participated in the 7 FGDs. Study participants resided in 25 different communities from within and up to 105 km away from the study venue/PHC location. Approximately 84% of participants resided in rural communities, while 16% were urban/periurban residents. There were more Christian participants (49/68, 72.1%) compared to Muslims (19/68, 27.9%). Details of participant characteristics are presented in Table
FGD participant characteristics (
G1 | G2 | G3 | G4 | G5 | G6 | G7 | All groups | |
---|---|---|---|---|---|---|---|---|
MM1 | MM2 | ANC1 | ANC2 | M2M1 | M2M2 | Young women | G1–G7 | |
|
|
|
|
|
|
|
|
|
Mean age (SD) | 28.6 (±5.0) | 33.3 (±3.4) | — |
— |
29.5 (±6.8) | 28.1 (±2.1) | 25.1 (±3.2) | 30.0 (±5.0) |
Other characteristics: |
||||||||
Location of FGD venue | Rural | Rural | Rural | Rural | Rural | Rural | Urban | |
Religion | ||||||||
Christianity | 0 (0.0) | 9 (90.0) | 8 (80.0) | 8 (80.0) | 6 (60.0) | 8 (88.9) | 10 (90.9) | 49 (72.1) |
Islam | 8 (100.0) | 1 (10.0) | 2 (20.0) | 2 (20.0) | 4 (40.0) | 1 (11.1) | 1 (9.1) | 19 (27.9) |
No response | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Marital status | ||||||||
Single | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 10 (90.9) | 10 (14.7) |
Married | 8 (100.0) | 10 (100.0) | 10 (100.0) | 10 (100.0) | 7 (70.0) | 9 (100.0) | 1 (9.1) | 55 (80.9) |
Polygamous marriage | 2 (25.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (28.6) | 0 (0.0) | 0 (0.0) | 4 (7.3) |
No response | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (30.0) | 0 (0.0) | 0 (0.0) | 3 (4.4) |
Living children | ||||||||
None | 0 (0.0) | 0 (0.0) | 3 (30.0) | 7 (70.0) | 0 (0.0) | 1 (11.1) | 10 (90.9) | 21 (30.9) |
1-2 | 4 (50.0) | 2 (20.0) | 4 (40.0) | 3 (30.0) | 4 (40.0) | 5 (55.6) | 1 (9.1) | 23 (33.8) |
3-4 | 4 (50.0) | 6 (60.0) | 3 (30.0) | 0 (0.0) | 3 (30.0) | 1 (11.1) | 0 (0.0) | 17 (25.0) |
>4 | 0 (0.0) | 2 (20.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (22.2) | 0 (0.0) | 4 (5.9) |
No response | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (30.0) | 0 (0.0) | 0 (0.0) | 3 (4.4) |
Formal education | ||||||||
None | 1 (12.5) | 0 (0.0) | 1 (10.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (2.9) |
Primary | 4 (50.0) | 2 (20.0) | 4 (40.0) | 1 (10.0) | 3 (30.0) | 2 (22.2) | 0 (0.0) | 16 (23.5) |
Secondary | 2 (25.0) | 6 (60.0) | 3 (30.0) | 4 (40.0) | 3 (30.0) | 7 (77.8) | 0 (0.0) | 25 (36.8) |
Tertiary | 1 (12.5) | 2 (20.0) | 2 (20.0) | 5 (50.0) | 1 (10.0) | 0 (0.0) | 11 (100.0) | 22 (32.4) |
No response | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (30.0) | 0 (0.0) | 0 (0.0) | 3 (4.4) |
Language of highest fluency | ||||||||
English | 0 (0.0) | 0 (0.0) | 1 (10.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 11 (100.0) | 12 (17.6) |
Hausa | 8 (100.0) | 1 (10.0) | 3 (30.0) | 1 (10.0) | 7 (70.0) | 1 (11.1) | 0 (0.0) | 21 (30.9) |
Igbo | 0 (0.0) | 0 (0.0) | 1 (10.0) | 3 (30.0) | 0 (0.0) | 3 (33.3) | 0 (0.0) | 7 (10.3) |
Others | 0 (0.0) | 4 (40.0) | 5 (50.0) | 6 (60.0) | 3 (30.0) | 5 (55.6) | 0 (0.0) | 23 (33.8) |
No response | 0 (0.0) | 5 (50.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 5 (7.4) |
Three themes emerged from the 7 FGDs: participants’ views on clinic-based ANC and delivery versus other options, preference for healthcare provider gender and religion, and the acceptability of Mentor Mothers (MMs) as a PMTCT service.
A few women reported prior home deliveries; however, these were not due to choice; the deliveries were imminent. A preference for facility-based deliveries, especially amongst HIV-positive women, emerged. Stated barriers to utilizing facility-based services (ANC and PMTCT) were living far away from clinics and unaffordable transportation fees: “
Nonavailability of male partners to accompany/transport women to the clinic for services also emerged as a barrier. Even when a woman planned a facility delivery, she may have to resort to home delivery if her partner was not available to transport her to the clinic at the onset of labor. “
All respondents preferred hospital delivery to home delivery. For those who were HIV-positive, knowing their status during pregnancy also encouraged them to deliver at the facility: “
Participants also articulated preference for clinic-based ANC. However, male partners’ opinions could supersede a woman’s preference for and utilization of skilled ANC: “
The majority of participants did not have a healthcare provider gender preference; they were simply concerned with receiving available services expeditiously. “
However, the women did express preference for a healthcare provider with an accommodating attitude. “
Young women specifically preferred male healthcare providers because they considered males to be more patient and understanding than their female counterparts: “
“
The choice of a certain gender therefore was not based on religious preference but rather professional attitude.
Responses from Mentor Mothers indicated that HIV-positive women were generally accepting and responsive to their services. Furthermore, Mentor Mothers identified two important factors necessary for a successful mentorship: mentors’ disclosure of their own HIV status to their mentees and a cordial, respectful Mentor Mother. Religious affiliation did not emerge as a barrier for acceptability of Mentor Mothers. “
On the other hand, Mentor Mothers indicated that women who had overcome the fear of HIV-related stigma were comfortable with Mentor Mother home visits. Again, religion did not appear to affect the development, or overcoming of the fear of stigma in associating with a Mentor Mother. “
Respondents across groups also acknowledged that MMs would be useful, especially for new mothers. “
Respondents were generally willing to accept the services of Mentor Mothers as “helpers” whether in a HIV or non-HIV context. However, they expressed preference for the services of trained Mentor Mothers to untrained female or male relatives. This was due to instances where friends and relatives gave unhelpful lay advice based on traditional myths, which could be confusing.
Among the largely mixed groups of Muslim and Christian women in our study population, religion did not appear to influence choices made towards healthcare facility patronage. On the contrary, the preference across both Muslim and Christian participants was to use healthcare facilities for maternal services. As stated in a Hadith (the records of sayings and preaching of the Prophet Muhammad Peace be Upon Him): “
A prior study identified geographical distance and transportation fees to clinic as the top two barriers to ANC access in Nigeria [
With respect to provider gender preference among women, our study findings deviate from what has been previously reported in Nigeria and other countries, where female providers were preferred [
Mentor Mother services were acceptable among all groups including HIV-positive women. However, community stigma associated with a HIV-positive status, and not religious affiliation of the mentor or mentee, limited Mentor Mothers’ abilities to counsel women in community or home settings.
In this study among women in rural North-Central Nigeria, we found little to support a significant role for Christian or Islamic religious beliefs in influencing maternal service uptake. This was an unexpected finding; however, it does not necessarily mean that more subtle religious influences are absent in this context. The one religious law that could be extrapolated and linked to poor uptake was the requirement of Muslim women to be accompanied by their husbands away from home. However, this particular Hadith’s saying was not mentioned or referred to by any of the Muslim participants during our study. Overall, barriers to utilizing maternal health services (geographical distance to facility, transportation cost, healthcare provider attitude, and gender roles with regard to decision-making) appear to be independent of religious influences. Our findings suggest that behavior and attitude with regard to maternal health service utilization in our North-Central study communities are similar amongst Muslims and Christians. In other words, religious influences on ANC and PMTCT service uptake appear to be more similar than different in our North-Central study communities where there is more equitable representation of both religions compared to the core North or South.
To encourage utilization of available maternal health services, important strategies to consider include advocating to and educating male partners on the importance of supporting access to and payment for facility-based maternal services without undermining their traditional decision-making roles. Where necessary, alternate family members should be nominated to facilitate pregnant women’s attendance at facility appointments or deliveries if a husband was unavailable. In addition, healthcare providers especially in rural areas should be made aware of the impact of negative or disrespectful attitudes to the success of ANC and PMTCT programs in Nigeria. Training targeting attitudinal changes and the adoption of professional behavior are sorely needed among rural-based healthcare workers, especially females, because they make up the gender majority of healthcare workers that clients are exposed to at PHCs. Finally, high-level, across-group acceptability of Mentor Mothers signals that the uptake of their peer mentoring services could improve service uptake and retention among HIV-positive women along the PMTCT cascade, regardless of their religious affiliations.
This study has some limitations. First, there were disproportionately more Christian than Muslim women participants represented, partly due to the fact that the study did not specifically target equal proportions of Christians versus Muslims. This in itself could reflect that access to and/or utilization of healthcare facility services may be lower among Muslim women, even if not necessarily due to religion itself. Our conclusion that health behaviors are similar among Christians and Muslims in North-Central Nigeria may have been modified if more Muslim women were represented in our study sample. Second, some study participants were recruited directly from clinics, for instance, ANC attendees, implying that they already had preference for facility-based services over alternate or home-based care. Furthermore, the study also did not evaluate for the socioeconomic status of Muslim versus Christian women. This may have guided the discussion of whether more severe lack of funds in women of one faith versus another may affect service uptake. Also, our study population was relatively small and may not represent the wider North-Central region. Lastly, the study population was in North-Central communities. The findings may be different if Muslim women in the core North and Christian women in the South were interviewed; adherence to religious laws within the dominant religion may be stricter in those areas and therefore more dichotomy in views and influences may be unearthed.
Our study approach was to interview largely mixed groups of Christian and Muslim women together in the same focus groups. There may be added value for future studies to interview homogenous Muslim and Christian groups of women as well as male partners in separate groups with the objective of assessing the influence of religious beliefs and practices on maternal health service uptake. Socioeconomic status should also be taken into consideration when recruiting participants or collecting sociodemographic data. Studies exploring religious influences on maternal service uptake exclusively among HIV-positive women may provide valuable information for PMTCT programs. Qualitative studies targeting religious leaders themselves would also add strength to future study findings on religion and maternal service uptake.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This paper reports part of the INSPIRE MoMent Nigeria study results. The authors would like to thank the Department of Foreign Affairs, Trade and Development, Canada, for funding the MoMent study. Sincere thanks also go to the WHO Geneva and Nigeria offices for their oversight and technical support throughout all stages of the MoMent study’s implementation. Finally, the authors thank the study participants for sharing their time, energy, and opinions during the Focus Group Discussions.