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Determinants of health care seeking behaviour during pregnancy in Ogun State, Nigeria Akeju, David O; Oladapo, Olufemi T; Vidler, Marianne; Akinmade, Adepoju A; Sawchuck, Diane; Qureshi, Rahat; Solarin, Muftaut; Adetoro, Olalekan O; von Dadelszen, Peter Jun 8, 2016

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RESEARCH Open AccessDeterminants of health care seekingbehaviour during pregnancy inOgun State, NigeriaDavid O. Akeju1*, Olufemi T. Oladapo2, Marianne Vidler3, Adepoju A. Akinmade4, Diane Sawchuck3, Rahat Qureshi5,Muftaut Solarin6, Olalekan O. Adetoro4,7, Peter von Dadelszen3 and and the CLIP Nigeria Feasibility Working GroupAbstractBackground: In Nigeria, women too often suffer the consequences of serious obstetric complications that maylead to death. Delay in seeking care (phase I delay) is a recognized contributor to adverse pregnancy outcomes.This qualitative study aimed to describe the health care seeking practices in pregnancy, as well as the socio-culturalfactors that influence these actions.Methods: The study was conducted in Ogun State, in south-western Nigeria. Data were collected through focusgroup discussions with pregnant women, recently pregnant mothers, male decision-makers, opinion leaders, traditionalbirth attendants, health workers, and health administrators. A thematic analysis approach was used with QSR NVivoversion 10.Results: Findings show that women utilized multiple care givers during pregnancy, with a preference for traditionalproviders. There was a strong sense of trust in traditional medicine, particularly that provided by traditional birthattendants who are long-term residents in the community. The patriarchal c influenced health-seeking behaviourin pregnancy. Economic factors contributed to the delay in access to appropriate services. There was a consistentconcern regarding the cost barrier in accessing health services. The challenges of accessing services were wellrecognised and these were greater when referral was to a higher level of care which in most cases attractedunaffordable costs.Conclusion: While the high cost of care is a deterrent to health seeking behaviour, the cost of death of a woman or achild to the family and community is immeasurable. The use of innovative mechanisms for health care financing maybe beneficial for women in these communities to reduce the barrier of high cost services. To reduce maternal deathsall stakeholders must be engaged in the process including policy makers, opinion leaders, health care consumers andproviders. Underlying socio-cultural factors, such as structure of patriarchy, must also be addressed to sustainablyimprove maternal health.Trial registration: NCT01911494Keywords: Health care, Pregnancy complicationsBackgroundAnnually, thousands of women are faced with pregnancy-related complications, most of which are attributed tohaemorrhage, puerperal sepsis, obstructed labour, hyper-tensive disorders, and unsafe abortions [1]. Over the lastthree decades, Nigeria continues to have one of thehighest maternal mortality ratios, with 496–560 deathsper 100,000 live births [2, 3]. This high mortality ratio isaccompanied by high fertility rates, increasing the obstet-ric risk for Nigerian women [4]. Women are at further riskof morbidity and mortality due to poor health seekingpractices and limited access to health facilities. There is agross deficiency in the distribution of health facilities;many communities in rural Nigeria do not have goodaccess to facilities staffed with qualified personnel [5]. This* Correspondence: davidakeju@gmail.com1Department of Sociology, University of Lagos, Lagos, NigeriaFull list of author information is available at the end of the article© 2016 Akeju et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Akeju et al. Reproductive Health 2016, 13(Suppl 1):32DOI 10.1186/s12978-016-0139-7insufficient number of facilities may partially account forthe low rate of institutional deliveries [4]. Furthermore,roads are often inaccessible and transportation systemsare problematic [5, 6].Others studies have also shown that the use of healthcare services is related to the availability, quality andcost of services, as well as to the social structure, healthbeliefs and personal characteristics of the users [7, 8].Cost affects health care behaviour significantly as doother socio-demographic factors such as occupation,parity, education, maternal age, and distance to healthfacility [9, 10]. Comprehensive antenatal care (ANC) hasthe capacity to reduce maternal mortality; however,many do not have the ability to pay for such services[11, 12]. In addition, a study conducted among womenin a south-eastern part of Nigeria showed that womenusually report late for ANC due to the belief that thereare no advantages in early booking, as ANC is perceivedprimarily as curative rather than preventive [13].Some studies have shown that health-related knowledgedoes not translate to increased utilization of services inpregnancy [14, 15]. In Nigeria, the ability of women toseek care is significantly moderated by the cost of ante-natal care [12]. Understanding social and cultural factorsthat influence health care seeking behaviour is critical forensuring safe pregnancies and deliveries. This study buildson previous work by investigating the influence of com-munity factors on a woman’s decision to seek care duringpregnancy in Ogun State, Nigeria.MethodsStudy siteThe study was conducted in four Local Government Areasin Ogun State, Nigeria: Ogijo, Yewa South, Imeko-Afonand Remo North (Table 1 and Fig. 1). Ogun State is one of36 states and is located in the southwest geo-politicalzone. It covers a total land area of 16,409 km2. It has aprojected population of 4.3 million people and thepredominant ethnic group is Yoruba. Farming is the mainoccupation, largely subsistence farming and cash crops ofcocoa and kolanut. In the urban and suburban areas, pettytrading and blue-collar jobs are the major occupation.Study designThis study is part of a larger initiative aimed at assessingcommunity level interventions for the management ofpre-eclampsia and eclampsia in Nigeria. An ethnographicframework was used to gain insight into the social andcultural realities at the community level, as these arethought to influence health seeking behaviours.Data was collected through focus group discussionswith pregnant women, recently pregnant mothers, maledecision-makers, opinion leaders, traditional birth at-tendants (TBAs), community health extension workers(CHEWs), nurses and midwives. In addition, interviewswere held with local administrative personnel, privatemedical practitioners, head TBAs, head CHEWs, chiefnursing officers, chief medical directors, medicalofficers, and community leaders (Tables 2 and 3). Eachfocus group discussion and interview was audio-recorded and transcribed. Data analysis was carried outusing NVivo version 10.The Health Research and Ethics Committee (HREC) ofOlabisi Onabanjo University Teaching Hospital, Sagamu,Nigeria (OOUTH/DA/326/431) and the Clinical ResearchEthics Board of the University of British Columbia,Vancouver, Canada (H12-00132), approved the study.ResultsThese results identified factors that influence health careseeking behaviour in pregnancy in Ogun. These factorsincluded location, time, obstetric condition and socio-cultural characteristics described below.Where women seek careRespondents reported patronizing multiple types of healthcare providers in pregnancy. Some women preferred ser-vices offered at the health centre or government hospital,however most favoured traditional doctors, prayer housesand TBAs in pregnancy. The use of traditional providersor prayer houses does not reportedly prevent women fromregistering at the health centre, and it was rare to findwomen who patronized only one type of provider.Pregnant women seek care at various places thesedays….some would go to a spiritual leader’s place andTable 1 Study site characteristicsNigeria characteristicsPopulation 159,288,426Size (Km2) 923, 768Number of states 36Number of geopolitical zones 6Predominant language Yoruba, Igbo, and HausaPredominant religions Christianity and IslamOgun State characteristicsPopulation 4,000,000Size (Km2) 16,409Number of local government areas 20Predominant language YorubaPredominant religion ChristianityLocal Government Area characteristicsCumulative population 469,271Cumulative size (Km2) 1657Number of study areas 4/40Akeju et al. Reproductive Health 2016, 13(Suppl 1):32 Page 68 of 97remain in hibernation…some would go to the herbalist’splace…some would go to the Islamic priest’s place….somewould go to “Iya l’osha”….and some would go to thehospital. All these places work…sometimes when apregnant woman seeks care at the hospital…it might getto a stage where the health care workers would ask thepregnant woman to seek alternative therapies….and thepregnant woman would return home…and she wouldwait for God to answer her prayers. A pregnant womancould seek help from all these places. [Opinion andReligious Leaders]Furthermore, some believed pregnancy complicationsrequired spiritual intervention; in these cases womenvisited “Iya l’osha” (a female priest) who is believed tocure complications of supernatural origin. In some cases,‘Iya l’osha’ was used as a last resort when all effortsusing orthodox medicine had failed.Some TBAs reported referring women with complica-tions to the health centre. According to one CHEW, closeto 60 % of women patronize TBAs, and when TBAs can-not handle an obstetric complication, they refer women tothe health centres.About 55–60 % prefer going to the TBA. […] Somewomen prefer going there and when there is anyproblem, some TBAs will refer them to health centres.[Community Health Extension Workers]It is evident that traditional providers have establishedthemselves in these communities. Women affirmed thattheir choice to patronize traditional providers was dueto the strong interpersonal relationships, reduced costand the ease of payment. This was well described by aCHEW during one of the discussions:The women cannot pay much money at the TBA …they can give them a drug that they have, after thetreatment, maybe 3 months after they would collecttheir money. But in government hospital you cannotFig. 1 Map of study sitesAkeju et al. Reproductive Health 2016, 13(Suppl 1):32 Page 69 of 97Table 2 Focus group discussion characteristicsNumber N participants Region Age (yr)Median [range]Religion1 Islam2 Christian3 Traditional religionN childrenMedian [range]% MarriedCommunity/Opinion Leaders1 12 Yewa South 52 [27,70] 1 = (N = 6)2 = (N = 6)5 [0,6] 100 %2 10 Remo North 44 [43,77] 1 = (N = 3)2 = (N = 5)3 = (N = 2)Not known 100 %3 12 Remo North 58 [30,85] Not known Not known 100 %4 10 Ogijo 50 [26,71] 1 = (N = 5)2 = (N = 5)6 [1, 9] 100 %5 12 Ogijo 57 [45, 72] 1 = (N = 3)2 = (N = 6)3 = (N = 3)8 [4, 10] 100 %6 12 Imeko-Afon 45 [20,55] 1 = (N = 6)2 = (N = 6)3 [0,10] 100 %Male Decision-Makers1 12 Yewa South 38 [27,49] 1 = (N = 2)2 = (N = 10)3 [1, 5] 100 %2 11 Remo North 40 [35,62] 1 = (N = 4)2 = (N = 6)3 = (N = 1)3 [0,9] 100 %3 12 Imeko-Afon 51 [40,60] 1 = (N = 11)2 = (N = 1)6 [4, 10] 100 %Recently Pregnant Mothers1 12 Yewa South 27 [20,42] 1 = (N = 6)2 = (N = 6)3 [1, 5] 100 %2 12 Yewa South 31 [20,42] 1 = (N = 4)2 = (N = 8)2 [1, 3] 100 %3 12 Remo North 29 [21,39] 1 = (N = 3)2 = (N = 9)4 [1, 6] 100 %4 12 Remo North 28 [21,34] 1 = (N = 5)2 = (N = 7)2 [1, 4] 100 %5 12 Ogijo 31 [26,43] 1 = (N = 4)2 = (N = 8)3 [1, 4] 92 %6 12 Ogijo 29 [22,38] 1 = (N = 1)2 = (N = 11)2 [1, 5] 100 %7 12 Imeko-Afon 30 [16,36] 1 = (N = 5)2 = (N = 7)3 [1, 5] 100 %8 11 Imeko-Afon 30 [18,36] 1 = (N = 6)2 = (N = 5)3 [1, 6] 100 %Pregnant Women1 12 Yewa South 26 [20,33] 1 = (N = 3)2 = (N = 9)1 [0,4] 100 %2 12 Yewa South 26 [20,39] 1 = (N = 4)2 = (N = 8)3 [1, 3] 100 %3 12 Remo North 30 [20,36] 1 = (N = 1)2 = (N = 11)1 [1, 3] 100 %4 12 Remo North 32 [23,40] 1 = (N = 5)2 = (N = 7)3 [1, 5] 100 %5 9 Ogijo 27 [19,34] 1 = (N = 6)2 = (N = 3)1 [0,2] 100 %Akeju et al. Reproductive Health 2016, 13(Suppl 1):32 Page 70 of 97allow them to come after 3 months when they’vereceived treatment… to come back and pay the money.So because of poverty, they prefer to go to TBA.[Community Health Extension Workers]In addition, respondents described a belief that“hospital medications only reduce the severity ofillnesses like malaria” whereas, “[a] local concoctioncleanses their body of all toxins.” The perception wasgenerally held that some complications are bettertreated by traditional doctors. Explaining this pointfurther, a male decision-maker described how womenpatronized both traditional health care providers andskilled professionals: “once they detect that the babyis lying across in the belly, they go to traditional doc-tors for care and they usually change the position ofthe baby to normal position”.While health care seeking behaviour is influenced bythe factors mentioned above, delays are influenced byadditional factors.When women seek careThe general view among the community and healthcare providers was that women accessed the formalhealth care system when they perceived they were atrisk. Usually, this was for delivery-related care, par-ticularly deliveries complicated by obstructed labouror retained placenta.They would come to us when they have complications…after they had gone to seek care at other place […] whenTable 3 Interview characteristicsNumber Stakeholder Group Cluster1 Head of Traditional Birth Attendants Sagamu2 Head of Traditional Birth Attendants Yewa South3 Head of Traditional Birth Attendants Imeko-Afon4 Head of Traditional Birth Attendants Remo North5 Community Leader Imeko-Afon6 Male Community Leaders Imeko-Afon7 Women Community Leaders Sagamu8 Women Community Leaders Imeko-Afon9 Women Community Leaders Remo North10 Opinion Leaders Yewa South11 Opinion Leaders Remo North12 Opinion Leaders Imeko AfonTable 2 Focus group discussion characteristics (Continued)6 10 Imeko-Afon 22 [19,26] 1 = (N = 7)2 = (N = 3)1 [0,4] 100 %7 12 Imeko-Afon 25 [20,30] 1 = (N = 2)2 = (N = 10)2 [0,4] 100 %Traditional Birth Attendants1 12 Yewa South 44 [32,65] 1 = (N = 7)1 = (N = 5)3 [1,4] 100 %2 12 Remo North 50 [41,77] 1 = (N = 1)2 = (N = 8)3 = (N = 2)5 [3,5] 100 %3 12 Ogijo 40 [25,50] 1 = (N = 5)2 = (N = 6)4 [0,5] 83 %Community Health Extension Workers1 12 Yewa South 40 [28,53] 1 = (N = 5)2 = (N = 7)3 [0,4] 100 %2 12 Yewa South 32 [28,55] 2 = (N12) 1 [0,4] 100 %3 12 Ogijo 38 [35,51] 1 = (N = 2)2 = (N = 10)3 [2,5] 100 %4 12 Ogijo 39 [33,50] 1 = (N = 4)2 = (N = 8)2 [2,5] 100 %5 11 Remo North 38 [32,50] 2 = (N = 11) 2 [0,5] 100 %Nurses and Midwives1 10 Ogijo 50 [30,53] 1 = (N = 2)2 = (N = 8)3 [1,4] 80 %2 12 Yewa South 49 [46,54] 1 = (N = 2)2 = (N = 8)3 [2,6] 83 %3 9 Remo North 46 [32,55] 1 = (N = 1)2 = (N = 8)3 [0,4] 78 %Akeju et al. Reproductive Health 2016, 13(Suppl 1):32 Page 71 of 97they encounter problems at those other places, theywould advise them that “you should go to the healthcentre” and the pregnant woman would just be helpless.[Community Health Extension Workers]In addition to obstetric complications which persuadewomen to seek care, the time of the day can be an im-portant factor in decision-making. Often, health care fa-cilities are closed at night due to human resourceconstraints; this unavailability causes women to deliverwith traditional providers. A new mother gave an ac-count that portrays this point.It wasn’t that I wanted to deliver at the herbalist’splace…initially, we went to a State Hospital…likearound 11:30 p.m. or about some minutes to 12:00midnight....the place was closed. We knocked andknocked on the door…in the middle of the night…noone answered. […] I was registered with the Statehospital […] I left there and decided to seek care fromthe herbalist because there was no other place for us togo to seek care. [New Mother]Frequent health facility closures are worsened by thesignificant distance, poor road access, and unavailabilityof transport late at night. In some cases, women pre-ferred to patronize traditional birth attendants, ratherthan travel long distances to seek care with qualifiedhealth personnel.Cultural factorsThe community indicated that women delay revealingtheir pregnancies as long as possible. It was believedthat early disclosure may lead to miscarriage and othercomplications. This belief was connected to the notionthat supernatural and diabolic forces had the potentialto influence pregnancy outcomes. As a result , routineactivities that could reveal pregnancy status, includingantenatal care, are reportedly avoided. Respondentsclaimed that it was common practice for women todelay antenatal care until the seventh month of preg-nancy. Some women chose to deliver with TBAs, asthey associated hospitals with surgical interventions,and there was a strong cultural preference for ‘un-assisted deliveries’.She was using a hospital. When it was time forher, they tested her and told her that her wombwasn’t wide enough for her to deliver the babyherself that she had to undergo a surgicaloperation…the moment she heard the word surgicaloperation instead of going to the hospital fortreatment, she went to the herbalist’s place. Shelabored for a long time at the herbalist’s place andlater, the herbalist asked her to leave when he sawthat he couldn’t handle the situation. She thenwent to a hospital, but the hospital rejectedher….and she died before she could get to theGeneral Hospital. [Male Decision-Maker]In addition to the fears of surgery, some also expressedfear of other hospital interventions, such as the use ofultrasound.It is the scan result that makes some pregnant womengo to the herbalist’s place to seek treatment. […]Health care workers could tell some pregnant womenthat their babies is lying in awkward position…..andthey might need to turn their babies to the rightposition.....this is what make many pregnant women togo to the herbalist’s place to seek care. [New Mother]To some extent, these cultural norms were influ-enced by gender relation and the culture of patriarchythat predominates in Nigeria. The study areas had adominant culture of patriarchy, and the man’s consentplayed a significant role in determining where andwhen a woman could seek health care. Discussionswith health workers showed that some women wouldnot start ANC until they were permitted to do so bytheir husband. Women who made independent healthcare decisions were considered to be arrogant, disres-pectful and in the word of one female participant,“too forward”.If the woman doesn’t seek the consent of the husbandbefore deciding where to seek care, the woman will beconsidered as being too forward. [Male Decision-Maker]Financial constraints and cost of servicesWomen delayed care seeking due to financial con-straints; women depended mainly on their husbands tosupply funds for health services. In cases where the hus-band was unable to pay, family members or friends mayhave covered the costs.Some of them might say that their spouses havenot given them the go-ahead to do so even if theyhave the money to pay. It is when the husbandhas money that she can come she cannot take thedecision on her own. [Community Health ExtensionWorker]Finances were a consistent barrier to health care ser-vices for many, and this barrier was greatest for higher-level care. Teenage mothers were felt to be at particu-larly high risk as they were less likely to be financiallyprepared. Reportedly, pregnant women tended to save inAkeju et al. Reproductive Health 2016, 13(Suppl 1):32 Page 72 of 97the event that it is required during pregnancy. Theytended to raise funds near delivery when costs werelikely to be incurred. It was perceived to be essential tohave funds protected in advance as it was uncertainwhat might happen during pregnancy.Pregnant women should not be tight fisted, if thehusband refuses to give money; the wife also needs toraise money for herself. [Pregnant Woman]To raise funds, family members sometimes sold property.In rare cases, health workers contributed when womenwere unable to pay. As such, the cost of services greatlyinfluenced the choice of provider and facility. Cost alsoinfluenced the ability of women to follow through withreferrals.I was sick during pregnancy and I went to theState Hospital, they wrote me a bill of over fourthousand Naira when they hadn’t even given me asingle medication. They didn’t even offer meparacetamol to use, they just abandoned me on thebed. My husband was running around to raisemoney. [New Mother]Women patronize the herbalist, church or TBA becausethey allow delayed payment. According to a TBA “Theyalso choose us because it is more expensive to go to thehospital or health centres around here.” These outletsoperated on different modes of payment that enabledwomen to pay in instalments and with other forms ofpayment such as goats or palm oil. This made it easier forwomen to facilitate payment for health care with TBAs.DiscussionThese findings demonstrate that women commonly utilizeseveral obstetric health care providers in complement dur-ing pregnancy: traditional birth attendants, faith-basedproviders, and orthodox practitioners (nurses, midwives,community health workers, doctors, specialists). As de-scribed by a sample of community members, health caredecisions in pregnancy are influenced by cultural normsand beliefs, perceived quality of care, time of day, cost ofservices, and transport options.Health care decisions in pregnancy can be explained byuse of the Health Belief Model, which states that individ-uals weigh the potential benefits against the psychological,physical and financial costs when making decision to seekcare, as was reflected in these findings [16]. In mostAfrican societies, the status of women is low [17] andfamilies are patriarchal, with men responsible for keydecisions. The patriarchal family structure rests on men'scontrol over property; this often extends to the wife ashis possession. It is within this cultural milieu of male-dominance that women enter into marriage, child bear-ing and child rearing in Nigeria. The patriarchal culturegives women little or no power to decide when theybecome pregnant, or how, when, and where to seekcare during complications [17]. While patriarchy is aculturally entrenched factor that subjugates women , lackof financial empowerment further compounds women’sinabilities to determine where, when and how they mayseek care during pregnancy. Thus the inability of most Ni-gerian women to pay for maternal health services drivesthem to alternatives such as the use of local herbs andconsultation with traditional birth attendants and doctors.Government hospitals are usually patronized when all al-ternatives have been exhausted. Against the backdrop ofendemic poverty, women are constrained from seekingcare at the health centre or government hospital. As ob-served in a recent study [18], the cost of transport is anadditional cost to care seeking. Distance to health facilityis unequal, greatest in rural areas and tends to escalate thecost of care.The strength of this study lies in its adoption of anethnographic framework, enriched by real life experi-ences and realities of health care providers and patients.Although the study has been able to describe some de-terminants of health care seeking behaviour, a limitationis that we cannot infer causation of these factors and theobserved outcomes beyond the study sites. It is expectedthat similar socio-cultural factors underpin health caredecision making in other rural African communities;however, due to the qualitative nature of this studygeneralizability cannot be presumed.It is important for the Nigerian government to reducefinancial barriers by decreasing the cost or providingfree health services in pregnancy. Although the provisionof free health care services was reported in Ogun State,this change has not reached all areas of the state. Inaddition, targeted health messaging should be providedto reduce knowledge gaps, empower pregnant womenand engage community leaders. These findings shouldbe used to guide health messaging to increase utilizationof maternal health care services. It is evident thatsuch educational approaches must dispel harmfulmyths surrounding pregnancy, such as the effect ofearly pregnancy disclosure, as well as highlighting theimportance of facility-based care to improve maternaloutcomes. These public health messages should alsoinclude important health system information, such asfacility location and hours. The findings of this studyhave been presented to key local stakeholder groupsthrough meetings which included local media coverage.Attendants at these events included pregnant women andfamilies, community-based health care providers, andcurrent and past government representatives at the localand state level.Akeju et al. Reproductive Health 2016, 13(Suppl 1):32 Page 73 of 97ConclusionA community participatory approach is needed to co-ordinate maternal health services in Ogun State andNigeria at large. Efforts should be made towards commu-nity engagement and education to better integrate variousproviders and community stakeholders, including maledecision-makers. Educational messaging should high-light the importance of appropriate and timely accessto health care services. Cost of care must also be ad-dressed; one option is incorporating a communityfinancing scheme into the National Health InsuranceScheme. There is of course no magic bullet; all solutionsare long-term approaches which require considerablefinancial investment.Peer reviewPeer review reports for this article can be found inAdditional file 1.Additional fileAdditional file 1: Peer review reports. (PDF 329 kb)AbbreviationsANC: antenatal care; CHEWs: community health extension workers;TBAs: traditional birth attendants.Competing interestsThe authors declare that they have no competing interests.Author’s contributionsDOA developed the manuscript and oversaw data acquisition. MV and OTOconducted qualitative analyses. DS and RQ contributed to the conceptionand design of the study. OOA served as principal investigator for the study.AOA, MS, and PvD provided critically important revision of the manuscript.All authors read and approved the final manuscript.AcknowledgmentsThis work is part of the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported by theBill & Melinda Gates Foundation. We would like to thank all members of theCLIP Nigeria Feasibility Working Group: Bisi Orenuga, Bimpe Osiberu, BethPayne, Sharla Drebit, Chirag Kariya, Zulfiqar Bhutta and Laura Magee. Wegratefully acknowledge the contribution of those involved in the studyincluding the many participants and the communities of Ogun State.DeclarationsPublication charges for this supplement were funded by the University ofBritish Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Preventionand Treatment) initiative supported by the Bill & Melinda Gates Foundation.This article has been published as part of Reproductive Health Volume 13Supplement 1, 2016: Community insights from four low- and middle-incomecountries into normal and complicated pregnancies. The full contents of thesupplement are available online at http://reproductive-health-journal.biomed-central.com/articles/supplements/volume-13-supplement-1.Author details1Department of Sociology, University of Lagos, Lagos, Nigeria. 2UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research,Development and Research Training in Human Reproduction (HRP),Department of Reproductive Health and Research, World HealthOrganization, Geneva, Switzerland. 3Department of Obstetrics andGynaecology, and the Child and Family Research Unit, University of BritishColumbia, Vancouver, BC, Canada. 4Centre for Research in ReproductiveHealth, Sagamu, Ogun State, Nigeria. 5Department of Obstetrics andGynaecology, Aga Khan University, Karachi, Pakistan. 6Directorate Division ofMedical and Health Care Services, Ijebu Ode Local Government Secretariat,Ijebu Ode, Ogun State, Nigeria. 7Department of Obstetrics and Gynaecology,Olabisi Onabanjo University, Sagamu, Ogun State, Nigeria.Published: 8 June 2016References1. 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