MMSH is a secondary hospital in the Kano metropolis of Kano State in north-western Nigeria, with a population 13.4 million. Although there are more than 300 ethnic groups in Nigeria, most of the Kano population belong to the Hausa or Fulani ethnic groups, and are predominantly Muslim. ¹⁵ It is the largest government-owned hospital in Northern Nigeria and therefore draws a wide range of clients from across the state, making it a useful site to study our phenomenon of interest due to the diverse range of participants who attend this hospital. No fees are charged for consultation and admission, inclusive of antenatal services. This feature of service delivery also factored into our decision to carry out this study at this site, as it is more likely to bring in lower socioeconomic status families for whom anaemia is more likely to be a problem. There are 275 beds for obstetrics and gynaecology and a dedicated blood bank to collect from family members, which it screens for HIV and Hepatitis B and C using rapid testing.

Key informant interviews

Four key informant interviews were carried out with two policy makers and two hospital managers. Participants were sampled purposively due to their knowledge of policy-making that impacts care, interventions during pregnancy and childbirth, training of providers and oversight at hospitals. Prospective participants were contacted in-person or by phone by AKG and were given information about the study. They were given more than 24 hours to decide whether they wanted to participate or not. Interviews were conducted by AKG in a private room within the hospital or the participant’s workplace, wherever participants felt comfortable, and lasted for 30–100 minutes.

In-depth interviews

In-depth interviews were carried out with ten healthcare providers (doctors, nurses, laboratory staff, or community health extension workers who screen women and refer them to midwives) and 18 pregnant women. Providers were sampled purposively based on their experience in pregnancy anaemia management. Pregnant participants were sampled purposively to maximize diversity around the following characteristics: parity; duration of pregnancy; and prior experience of blood transfusion. Sampling was carried out until theoretical saturation had been reached.

AKG identified prospective healthcare providers through working with department heads, and approached them directly to provide information about the study. They were informed that this would be to gain their perspectives about providing anaemia care and would in no way be used to evaluate their performance. They had a week to consider their participation. Pregnant women were recruited in the waiting hall of the MMSH antenatal clinic. They were approached by AKG—who is in no way involved in their care—and were given information about the study, namely that they would be asked questions about their experiences of anaemia care and what might influence their uptake of this care. They had a full day to consider their participation.

Interview guides for providers focused on existing policies and services offered across the spectrum of care during pregnancy, childbirth and into the post-partum period, inclusive of the diagnosis and management of maternal anaemia. Interview guides for pregnant women focused on understanding of anaemia and experiences of care during pregnancy and childbirth. These guides were developed following an extensive reading of the literature and author AKG’s intimate knowledge of the context.

Interviews with providers and pregnant women were scheduled at their convenience, and for providers, took place in private spaces in the hospital. Some women needed permission from husbands or relatives and were given a contact number to confirm participation. Most interviews with pregnant women were held in the matron’s office at the antenatal clinic. However, those who confirmed participation after obtaining permission had their interviews conducted at AKG’s office in Aminu Kano Teaching hospital. Interviews took 30–40 minutes.

Focus group discussions

Four focus group discussions (FGDs) were held with women’s relatives, each with six participants: two groups of six husbands and two groups of six mothers-in-law. Snowball sampling was used to identify participants, as women who participated in interviews were asked to inform their husbands and their mothers-in-law about the research and to invite them to participate in FGDs. Those who agreed were contacted by telephone and FGDs were organized.

Discussion guides focused on participants’ understanding of anaemia and perceptions of care received by their partners or daughters-in-law during pregnancy and childbirth.

All interviews and FGDs were carried out by AKG—who has extensive training in social science methodology—in Hausa or English. All interviews and FGDs were audio-recorded, transcribed verbatim, and later translated into English if necessary. Handwritten notes to capture non-verbal communication were made during interviews and FGDs by a research assistant. Interviews took 20–60 minutes and FGDs took 45–70 minutes.

Thematic analysis was used. ¹⁶ All steps of the data analysis were carried out by AKG, TT, and DG. Data were read and re-read for familiarity. Line-by-line inductive coding was carried out and a coding framework was established in Excel. Codes were grouped into higher-order codes and themes. Applying and refining the coding framework was repeated until no new codes were generated and thematic saturation was reached, at which point, participant recruitment ceased.

The following four themes emerged: guidelines and policies for managing anaemia; quality of care; resources and financing; and knowledge, attitudes and practices of women and family members. These are described in the results that follow.

All participants are described in Table 1.

Key informants and providers summarized the guidelines and policies for managing anaemia. Pregnant women are seen first between 20 and 28 weeks. Before consultation, they receive anaemia education on topics including: issues in pregnancy, childbirth and when breastfeeding; risk factors; signs and symptoms; prevention using diet; treatment; and the importance of child spacing. During antenatal care consultations, pregnancy is confirmed using last menstrual period, the estimated due date is calculated, and the women are tested for blood group, packed cell volume and infections.

Healthcare professionals are expected to treat anaemia based on an individual assessment using their clinical judgement, the client’s estimated packed cell volume, severity of anaemia and likely cause. Most pregnant women are administered precautionary oral iron supplements because iron deficiency anaemia is very common. Women with severe anaemia are thought to be from rural areas and may not have attended antenatal care. Blood transfusion is indicated in those with associated dizziness and weakness.

Providers reported there was no concerted effort to ensure that staff were trained on guidelines for anaemia diagnosis and management, or that guidance was fully implemented or monitored.

Healthcare professionals reported that, as per Kano state policy, care to women during pregnancy, childbirth, and in the postpartum period is free, including a packed cell volume screen, supplements, and medication to prevent/treat anaemia and dietary advice. Participants clarified that blood transfusions were also included for free, provided patients’ relatives donated blood to replace units used.

As subsequent results suggest, there is a mismatch between the policies and guidelines that exist and the practices that take place.

Healthcare providers were knowledgeable about maternal anaemia and its often-complex origins. There was recognition that there is not always the ability to address all possible causes, which would necessitate nutrition counselling, iron, and folic acid supplementation—and adherence, malaria prophylaxis, deworming, and child spacing, among other interventions. The nutritional and child-spacing aspects were understood as being culturally mediated and difficult to change.

Healthcare professionals and women reported several issues that affected access to and the quality of care: high staff turnover and inadequate staffing, particularly of specialist physicians; high demand for care; insufficient remuneration for staff; and unsatisfactory supervisory support.

Hospital managers, women and relatives reported that free provision was responsible for a drastic increase in women attending the service, which placed a strain on service delivery. This is because the service was attracting users from nearby states such as Jigawa, as well as an influx of clients previously unable to afford care.

Healthcare professionals reported that staff often did not take time to properly consult with patients, in addition to huge workload, because of other commitments outside the hospital.

Consequently, time for one-on-one counselling regarding medication compliance was limited, and there was reduced ability to diagnose women with anaemia in the early stages. Many women and relatives felt unable to discuss problems with staff because there was a lack of privacy during consultations due to crowded waiting areas. Staff also appeared rushed and disengaged, which women regularly noted prevented them from raising potential concerns.

Appropriate maternal anaemia care may be constrained by a lack of training and, as above, lack of specific guidelines. For example, providers understood that maternal anaemia is defined as a low packed cell volume in pregnancy or the postnatal period and relied on estimates of this to diagnose anaemia. However, providers’ perceptions of the cut-off values at which anaemia would be indicated—some stated 20%, others 25% and others 30%—were inconsistent.

For blood transfusions, staff relied on knowledge from books and the experience of senior colleagues as opposed to local standards of practice, which were not used. Hospital managers and healthcare providers reported no formally scheduled staff training on maternal anaemia, with staff required to use their experience to provide on-the-job training.

Healthcare providers reported that they were often unable to diagnose causes of maternal anaemia because specific tests were unavailable or too costly. As a result, reliance was on clinical and symptom-based diagnosis, which can often only identify anaemia when it is very severe.

Furthermore, causes of anaemia were rarely investigated, due to too much perceived demand, which may constrain appropriate care.

Healthcare providers reported stocks of medication were often inadequate because demand out-weighed supply.

Hospital managers also acknowledged that reporting stockouts was not always well-received at higher levels. These participants therefore reported attempts to generate resources and support free care by diverting funds away from the drug revolving fund—a fund generated by drug sales, laboratory tests and other hospital services intended to maintain services.

Despite existing policies, women and relatives reported often purchasing medications from pharmacies—or from staff—along with making other out-of-pocket expenses, like paying for packed cell volume testing. Women and their husbands corroborated this finding, widely reporting the expenses associated with seeking care. These expenses were seen as making uptake of care, or use of appropriate medications, inaccessible for some due to widespread poverty.

Blood availability remains a major constraining factor in treating anaemia. In emergencies, medical staff collecting blood for transfusion from the blood bank are responsible for ensuring that, prior to patient discharge, the patient’s family provide replacement blood.

Because blood type may be rare and consumables such as blood bags must be bought, significant delays can occur. Relatives are often not available when there is an urgent need, so it can take hours to obtain a donation, screen for infections and crossmatch. The most common reason for rejection of donated blood is the presence of Hepatitis B virus markers. Despite need for transfusion, if blood, or a specialist able to administer the transfusion, is not available, it will not take place. Multiple participants spoke of instances where they or their partner were awaiting a transfusion that never took place.

Participants reported that obtaining donor blood is slow and difficult due to: negative cultural connotations of having another person’s blood in one’s system; low level of awareness of maternal anaemia in the public; fear of being diagnosed with an unknown disease; belief that they do not have enough blood to donate; belief that a financial burden will be incurred; and public distrust of transfusion services. The difficulty in sourcing donors leads some to abscond from the ward after transfusion without replacing blood. Consequently, blood bank staff often refuse to accept emergency requests for blood, exacerbating the issue.

Most women and relatives described anaemia in terms of its symptoms, some mistakenly equating anaemia to blood pressure. Most reported poor diet and blood loss as causes, but inconsistently related repeated pregnancies at short intervals to anaemia. Relatives mostly related maternal anaemia to low blood levels from inadequate diet or early pregnancy. Healthcare professionals reported that often, even after education, women still become anaemic. There are several reasons for this. Some women reported that many did not engage fully with education and were distracted, while others reported that the time would have been better used for one-on-one consultations.

Healthcare professionals reported that medication and dietary advice are sometimes not followed, in part due to lack of understanding, inconsistent antenatal care attendance, illiteracy and lack of anaemia education as well as poor perception of hospital care. Prescriptions are often lost and not re-administered until the following visit.

Some women dislike taking the medications like iron and folic acid supplementation, which are prescribed routinely, while others were not aware that drugs were prescribed and were unclear on medication guidance.

Many women continued to believe that there was no cure for maternal anaemia, but that a range of traditional herbal treatments alleviate symptoms. Traditional healers are cheap, known to the family, live locally, can provide care to women at home, and women do not require permission to seek their assistance.

However, women and relatives explained that if traditional treatments fail, the condition may become severe, and women will eventually have to seek hospital care.

However, attending hospital care was sometimes seen as burdensome, taking women away from domestic responsibilities, which must be completed upon their return.

Women, husbands, and relatives saw anaemia as a source of familial friction, especially because women ordinarily needed to gain the permission of husbands and/or mothers-in-law to attend hospital appointments. Though most husbands reported supporting their wives for healthcare costs, healthcare professionals reported that women were often financially dependent on husbands who could not, or would not, provide enough money for women to treat their anaemia and effectively feed the family. Poor economic status of women often disempowers them and further constrains their decision-making.

Relatives reported that women did not always accurately relay information to their husbands from the clinic because they may have forgotten or misunderstood. They reported that women were sometimes too shy to raise problems with staff. Some women added that being attended to by male staff would aggravate some husbands.

One woman explained that blood transfusions could also cause arguments between husbands and relatives, because they feel that the need for a transfusion means that the husband does not take proper care of his wife.

Most women reported that they would be happy to have their husbands in attendance at antenatal appointments, because they felt their husbands could communicate concerns directly to caregivers and were more likely to believe advice directly from hospital staff. Women reported that most husbands did not attend because of cultural norms, particularly the fear of embarrassment if seen accompanying a woman to the antenatal care or for childbirth. Some husbands responded that they would be glad to attend the antenatal care with their wives, but that this would mean taking time off work, being in a crowded space in the clinic and interacting with other women. Consequently, only a few reported attending and instead supported their wives financially.

A strength of this research is that it draws on multiple perspectives from a range of health systems actors, which allowed both supply- and demand-side factors to be highlighted. Further, there are limited studies around experiences of maternal care services specific to anaemia, which is a significant problem globally, but especially in Sub-Saharan Africa.

A key limitation is that interviews were conducted with women who were already accessing services. These participants had overcome many barriers to accessing these services, and there was an increased likelihood that those interviewed were more sympathetic to institutional healthcare. It is possible that those who were unable to access these services experience other barriers that are not discussed here, requiring further research.