Qualitative Research on Communication Needs and Channels: Study Report Assessment of Communications Needs for Obstetric Fistula Programing in Nigeria

The study aimed to identify key information gaps related to maternal health and childbirth injury prevention and treatment that need to be addressed through fistula prevention and treatment communications strategies. The study also sought to identify the best communications channels to reach women of reproductive age and their partners, other influential household decision-makers, and women living with childbirth injuries. The study targeted five of the 11 states where FC+ is active in Nigeria: Bauchi, Zamfara, Ebonyi, Cross River, and Kwara. The study included four types of data collection: qualitative investigation at the community, health system, and policymaker level; an inventory of communications partners in each state; a quantitative review of fistula patient records; and a feedback exercise reviewing existing communications materials with community members in each state. Qualitative data were obtained through focus group discussions (FGDs) and in-depth interviews (IDIs). Community respondents displayed a great deal of ambivalence and heterogeneity in their attitudes about facility-based health services. Positive attitudes about the benefits of care seeking often went hand in hand with preferences for traditional providers, skepticism about quality of care, and concern about a wide range of access barriers. Women of reproductive age were often quite positive, in principle, about seeking antenatal care (ANC) and skilled care at delivery. Male community members also sometimes expressed support for facility-based delivery. Fistula patients in particular emphasized the importance of spending money on hospital care in order to keep women from “dying unnecessarily” and discussed seeking skilled care in very positive terms. This was notable given that several fistula patients identified neglect and delays at the health facility as factors in causing their condition. Both community members and health facility staff described several issues that act as barriers to seeking and receiving services that can prevent fistula and other childbirth injuries. Frequently-cited barriers that could be targeted by community-focused social and behavior change communication (SBCC) include poor birth preparation, low awareness about health services, requiring husbands’ permission to seek care/disapproval of care seeking from husbands and other family members, preference for traditional birth attendants (TBAs) and techniques, expectations attached to gender roles, belief that only God has control over birth processes and outcomes, and lack of confidence that health facilities can provide an adequate standard of care. Notably, both community members and health system personnel emphasized ANC as essential in preventing fistula, often giving it greater priority in their comments than skilled care at birth or emergency obstetric care. Some respondents noted that “registering at the hospital” if pregnant was a preventive strategy. This may indicate that women who have sought ANC have a false sense of confidence that they are not at risk and/or that potential complications can be definitively identified during ANC. In multiple states, women of reproductive age described preparing for birth, for example through purchasing materials such as razors, baby clothing, food, and blood. Fistula clients stated that there had been no taboos against preparing for birth. Despite the generally positive views about facility care-seeking and birth preparation expressed by community members, health system personnel and policymakers felt that families don’t prepare well and only seek skilled care at health facilities if they experience danger signs before or during labor. Two other aspects of childbirth injury prevention were discussed by community and health system respondents: early marriage and family planning. Underage marriage was described by many respondents in Bauchi, Cross River, Kwara, and Zamfara as a known cause of birth injuries and spoken of negatively. In Ebonyi, some respondents suggested that early marriage was a response to (or preventive of) immoral behavior by girls. Across states, respondents highlighted the need for effective communication strategies to address these issues and promote healthy behaviors.