'It's a normal thing for pregnant women' - pregnant women 'playing by the rules' in antenatal centres with routine tetanus vaccination in Nigeria: an explorative study

Abstract

BACKGROUND: Although the World Health Organisation (WHO) recommends vaccination during pregnancy to all pregnant women; the delay or incomplete use of vaccines has been a challenge globally. The data in Nigeria indicates only 62% of pregnant women receive two of five recommended doses of tetanus-toxoid containing vaccine (TTCV), way less than the 80% required by WHO for maternal and neonatal tetanus elimination (MNTE). It is well known that one of the most effective ways of eliminating tetanus disease, particularly in high-risk countries is adequate vaccination of pregnant and childbearing-age women. The recommendation in Nigeria largely concentrates on one to three doses during pregnancy depending on when a pregnant woman initiates antenatal booking, paying less attention to the issue of completion of doses after the child is born. The majority of research in this area heavily emphasises the roles of the health system, care providers and pregnant women in regard to the routine use of TTCV in antenatal centres, highlighting the lack of understanding of what TTCV is within everyday social interaction. Nevertheless, there is a notable lack of research into pregnant women’s perceptions of their experiences of the use of TTCV in antenatal centres.

AIMS: This research study explores how pregnant women in different antenatal centres in Nigeria perceive routine vaccination with TTCV and examines factors that influence this perception. Design and method: Qualitative interpretative research was conducted in three antenatal care centres in Ogun State, Nigeria. The antenatal settings were: 1) hospital; 2) tradition based; and 3) faith-based centres. In-depth semi-structured interviews were conducted with forty-one (41) childbearing-aged pregnant women in English and Yoruba languages between October 2019 and February 2020. Following transcription and translation, data management was facilitated using NVivo 12 and thematic analysis was used to identify, analyse, and categorise the data into themes.

FINDINGS: The analysis identified three major themes demonstrating the pregnant women’s perceptions of routine tetanus vaccination as: 1) making antenatal centre preferences, 2) relational and value alignment and 3) ‘playing by the rules’ in preferred antenatal centres. Findings revealed that TTCV was not only perceived as maintaining the ‘status quo’ in different antenatal centres but that largely, the pregnant women paid less attention to the use of TTCV. The belief that caregivers in antenatal centres have the best interest of the pregnant women caused them to mainly concentrate on the form of care to seek during pregnancy – formal, informal or both. To make the decision on preferred antenatal centres, the pregnant women ii aligned with relationships and beliefs that they found valuable to their choice of antenatal centres and followed the existing order in their preferred centres, including vaccination with TTCV. The participants followed the use of one to three doses of the five recommended doses of TTCV depending on when they registered and started antenatal care. The pregnant women felt that there was no need to “ask doctors the meaning of this injection”, since it was recommended by their caregivers and that previously pregnant and other women used the vaccine. The pregnant women in this study engaged in the use of the ‘usual’ one to three doses of TTCV as a rule of pregnancy care and did not necessarily complete the recommended doses after the child is born, a form of ‘game playing’. The metaphor of game playing indicates the strategy of the pregnant women of successfully getting through the period of pregnancy by following the rules that are believed to be in the interest of a healthy baby and not for themselves. The pregnant women engaged in vaccination with less participation in the process by solely acting in accordance with routines and antenatal set rules. Drawing on Bourdieu (1990) concept of practice and his conceptual triad of field, habitus and capital, this study’s findings demonstrate most pregnant women were neither involved nor engaged in vaccination but did use TTCV as “raison d'etre”, which is important to achieve a positive pregnancy outcome, and as a “socially recognised” and a worthwhile routine to engage (Bourdieu, 1990:18). Not that the pregnant women naively acted in accordance with the antenatal set rules, but they strategically preserved antenatal routines mainly for the purpose of a healthy pregnancy outcome. According to Bourdieu and Wacquant (1992), players/agents come to the field with the intention to either change or preserve their boundaries while they struggle for their rewards. In this light, the pregnant women perceived TTCV as maintaining a standard of pregnancy care in their preferred antenatal centres, largely as a means to a possible healthy baby, and not a routine to continue after the child is born. Implication: This study highlighted the ways that the health system in Nigeria does not meet the vaccination information needs of pregnant women. It also raises the potential for an innovative approach to address the informality that underlines the use of TTCV suggesting the need for a deliberate, constructive, and efficient information dissemination to support the pregnant women in their vaccination with TTCV. This study also suggests ways that vaccination education could be pivotal in meeting the vaccination information needs of pregnant women in Nigeria, with a focus on re-educating health professionals on adequate vaccination as well as involving the formal and informal stakeholders in vaccine administration. Finally, this study suggests that TTCV recommendation tone should be focused on motherhood rather than on the period of pregnancy in order to extend the priority of women of routine vaccination with TTCV. In other words, extend the game playing with TTCV beyond the period of pregnancy.