This study found that COVID-19 created negative and positive experiences for midwives and TBAs in Lagos State, and identified areas to improve support for maternity care workers. Participants perceived that COVID-19 exacerbated challenges to women’s access and uptake of maternity care, and suggested methods to improve access to skilled maternity care. These findings support and add depth to global literature of this emerging topic.
Suggestions to improve support for maternity care workers
Following United Nations Population Fund’s (UNFPA) stance to ‘maintain a healthy workforce’ [
12], our study highlights how maternity care workers in Lagos could be better supported during pandemics. Midwives and TBAs sampled in our study identified key challenges to their willingness and ability to work during COVID-19, including fears about personal risk of infection, uncertainty, inadequate PPE, lack of support, stress, and burnout. These findings are consistent with a global survey [
25], and also align with a 2020 survey of maternity providers in Lagos which found 87.2% had experienced burnout since COVID-19 [
26]. Evidence shows that providers have been vulnerable to significant mental stress during COVID-19 [
39,
40]. Psychological interventions could be used to reduce anxiety, cultivate resilience, and support mental wellbeing of health workers during highly stressful events such as pandemics [
41]. A systematic review highlighted that further research is needed to determine the effectiveness of interventions to support the resilience and mental health of frontline workers during pandemics [
42]. Most participants in our study were female, and they described specific challenges of fear of infecting family and child-caring responsibilities. This finding is in accordance with literature that suggests that female health workers have disproportionate family responsibilities, which could exacerbate physical and emotional burdens during COVID-19 [
43,
44].
Consistent with our study, research into public health emergencies has identified that maternity care workers’ sense of duty overrides challenges, and is a motivator for willingness to work [
45]. Our study suggested that willingness to work was strengthened by commitment to patient care, faith, and family support. Given that data collection occurred one year after the pandemic started, a positive finding among participants was professional development, including the ability to “learn a new way of living” to cope with challenges. This temporal change is reflected in literature that suggests that processes of adaptation and personal development can build resilience and ability to cope with stressful conditions [
46,
47]. Individual-led coping strategies should be accompanied by organisation-led interventions to improve willingness and ability to work. A recent qualitative study of Indonesian midwives found that adequate protection through PPE availability, effective training and wellbeing support is needed to support midwives in providing maternity care during the pandemic [
48]. Maternity providers suggested that Lagos State Government could increase preparedness by providing adequate PPE and training, financial support, transportation for workers, and COVID-19 testing for health workers and pregnant women. Similar to a global survey [
25], maternity providers in Lagos reported difficulties in reaching their workplace due to travel restrictions. A key enabler for ability to work was government provision of transport for maternity workers [
49]. Participants referred to hierarchies of power within the health system, particularly a lack of decision-making abilities for nurses and midwives, which limited their choices in working conditions and redeployment [
50]. Health leaders should create a “conducive environment” to raise concerns and allow workplace flexibility. UNFPA has highlighted the need to expand the global maternity care workforce and invest in midwife-led improvements to maternity service delivery, particularly midwifery leadership and governance [
51]. Maternity care workers are influential advocates at community-level, and should be given adequate representation in leadership roles to guide health policies [
52]. Given significant ‘brain drain’ of the Nigerian health workforce, the government should focus on improving working environments and satisfaction to increase retention and capacity to cope with future outbreaks [
53,
54].
Maintaining access to maternity care during COVID-19
Despite WHO guidelines to maintain access to essential maternity services during the pandemic
[55], a combination of physical, financial, healthcare and social factors limited access and uptake of maternity care in Lagos [
49]. Participants in our study described key barriers, including movement restrictions, transportation, and financial inaccessibility. This was corroborated by a survey of women aged 15–49 years in Lagos, with other challenges being fear of contracting COVID-19, and mandatory face mask use at facilities [
56]. Our study aligns with global concerns about the indirect effects of the pandemic on increased risk of maternal and newborn complications and mortality, particularly in low resource settings [
8]. Maternity workers in our study described delayed health seeking, missed immunisations, and reduced antenatal registrations. Similar findings were observed in other LMICs during COVID-19, such as reduced institutional births and increased stillbirth rate in Nepal [
57], and community fear of facilities in India [
58]. Maternity systems must be strengthened to avoid persistent reduced uptake of skilled maternity services as was seen following Ebola [
6]. A global survey reported the negative impact of COVID-19 on respectful maternity care e.g. compromised standards of care, staff overwhelmed, reduced emotional and physical support for women [
59]. This warrants further exploration of current and long-term effects of COVID-19 pandemic on maternity systems and health seeking behaviours, both in Nigeria and other LMICs.
Participants suggested that the Lagos Government’s strategies to control COVID-19 should integrate approaches to improve access to maternity services. Maternity workers reported that financial difficulties were widespread during COVID-19, as evidenced by telephone surveys of Nigerian households that found opposition to strict lockdowns, because they exacerbate socioeconomic hardship [
60]. The Lagos State Government addressed financial barriers and provided free antenatal, delivery and laboratory services at primary healthcare centres during lockdown [
56]. Pre-COVID, LMICs including Nigeria relied on external support from NGOs e.g., maternity kit donations, to incentivise access to skilled maternity care. The role of NGOs during the COVID-19 pandemic could be further researched. Midwife participants commented that health worker shortages and new COVID-19 vaccination duties reduced their ability to run routine maternity services. To remedy this, governments should increase staff recruitment, and avoid redeployment of maternity providers to non-maternity care roles [
61].
Based on our study findings and consistent with global literature [
58], strategies to “allay fears” about COVID-19 and build trust in health systems during a public health crisis are key to maintaining access to skilled maternity care in Lagos. Participants recommended community outreach via various media (television, radio, social media) to address fears and stigma around COVID-19, encourage attendance of government facilities and strengthen patient-provider relationships. Midwives reported instances of women having unsupervised home deliveries, or preference for ‘unskilled’ TBAs. Patient preference for TBAs could be influenced by embedded traditions, as a survey of Nigerian households found 40% of respondents believed that COVID-19 could be cured by herbal remedies [
60]. Considering TBAs’ influential role in local communities, government and NGOs could engage TBAs as health promoters during public health outbreaks, and bridge the gap between community and skilled maternity providers [
62]. Community participation is essential in designing community health programmes during public health outbreaks such as COVID-19, which was highlighted by a study into the willingness and barriers to receive the COVID-19 vaccine among residents in the UK and Nigeria [
63]. Adding to a quantitative study of TBAs in Lagos [
27], our qualitative interviews with TBAs reflected a desire for more government training to develop knowledge of COVID-19 infection prevention and control. Referral pathways to skilled maternity services could be strengthened through mentoring of TBAs, and increased staffing [
64]. Collaboration between skilled maternity providers and TBAs could raise awareness about timely access to skilled care, to reduce risk to mother and baby, and improve public trust and satisfaction in maternity services [
56].
COVID-19 challenges the status quo, as telemedicine could provide remote access to care and peer support through digital communication platforms such as WhatsApp. However, COVID-19 heightens global disparities [
54], with limited telemedicine capacity in Lagos due to infrastructural constraints and cost barriers [
65]. A qualitative study among the general Nigerian population during the COVID-19 pandemic revealed the importance of remote access to care, and potential barriers to telemedicine including “poor internet service”, “concerns about confidentiality”, and “technological illiteracy” [
66]. Lagos State has launched the ‘Eko Telemed’ service as part of the new Health Scheme; however, this would need to be scaled up to fill this gap [
67].
Despite perceptions that maternity services were “picking up again”, subsequent highly contagious COVID-19 Delta and Omicron variants have propelled surges of COVID-19 infections in Nigeria since July 2021. Global COVID-19 vaccine distribution inequity means that Nigeria’s vaccination rate falls behind wealthier countries, with four million vaccine doses received between March and August 2021 [
68]. In addition to COVID-19, underutilisation of skilled attendants, poverty, and epidemics remain key obstacles to progress in maternal health in Nigeria [
69]. Aligning with WHO guidance, this study recommends that policymakers protect gains in maternal health, and prepare health systems and staff for future epidemics [
70]. Maternal indicators are sensitive markers of health system resilience, and close monitoring of provision and utilisation of services in terms of equity, access, coverage, and quality is required [
51].
Strengths and limitations
Strengths: We have not identified previous qualitative studies of maternity care workers in Nigeria in the peer-reviewed literature. Inclusion of midwives and TBAs gives broader insight into the impact of COVID-19 on maternity healthcare in a context where many women use the services of TBAs, although it is recognised that TBAs are not skilled birth attendants. Data saturation was achieved, with similar concepts repeated in the data.
Limitations: TBAs are highly heterogeneous; however, it was only possible to recruit TBAs registered with Lagos State Traditional Medicine Board. Unregistered TBAs are likely to be less connected to the health system and may offer different perspectives of the pandemic. Resource constraints meant that those who could not speak English were excluded, which may have reduced the diversity of participants. This work was only possible due to funding of CL as part of an international health study programme, and local research staff capacity was not available to undertake data collection. Cultural differences between the primary researcher (female, British, medical student) and participants may have impacted on data collection and interpretation of data. While impossible to eliminate completely, to mitigate its impact the research team worked closely throughout, reviewed audio and transcribed data, met frequently, and adopted a reflexive approach, drawing extensively on input from TO, an academic Lagos-based public health doctor with experience of both the local context, and qualitative research. CL was a novice qualitative researcher, but received formal training and close supervision by TO and BT (an experienced qualitative researcher) throughout. Remote data collection was generally successful but technical issues compromised some audio quality and non-verbal cues. Lagos State has comparatively generous resources for health, reducing transferability of findings to other regions of Nigeria [
71].