This is the first qualitative study to explore the views of Nigerian medical doctors regarding maternal self-medication with antibiotics. Seven key themes emerged suggesting antibiotic prescribing is routine in antenatal care, and antimicrobial self-medication among pregnant women is a recognised problem, including use of herbal medicines. There are no policy guidelines for managing the problem in primary care. Furthermore, participants welcomed the idea of a practical point-of-care test for detecting self-medication in antenatal care. These findings extend previous research on medication misuse in pregnant women from sub-Saharan Africa (8–11, 24, 32). Although past studies suggest a high prevalence in Nigeria (9, 10), compared to other sub-Saharan African countries (28–31), there has been no qualitative analysis of the problem from the point of view of a key stakeholder group with significant influence over antibiotic stewardship policy (44).
Self-medication with medicinal herbs was a major concern, supporting previous research showing the practice is widespread across sub-Saharan Africa (58–60), often to relieve illness symptoms (61). The doctors believed use of herbal medicines during pregnancy is endemic amongst Nigerian women (9–11). Although there was no consensus regarding the type and/or biochemical content of herbs used, limited access to antibiotics (e.g., due to high financial cost) was believed to be a factor encouraging reliance on traditional medicines. While certain herbs do have antimicrobial properties, a typical medicinal herb (e.g., plant extract) may contain over 150 chemical ingredients, making identification of adverse effects and drug interactions difficult (62). Thus, the doctors did not recommend herbal medicinal use during pregnancy (63).
The ease with which pregnant women obtain antibiotics without a prescription was highlighted, supporting past research suggesting medicines are readily available in sub-Saharan Africa, (e.g., from local traditional healers, family members, or OTC sales) (9, 17, 30). Naturally occurring herbal products are also readily available (24). Research indicates that traditional medicines can be obtained from multiple sources, including friends and family, or local traditional healers (native doctors) (59, 64, 65).
Detecting and monitoring medication misuse was a challenge. While many doctors relied on history taking, and/or recording side effects that might indicate antibiotic use, most accepted the need for a cost-effective and practical point-of-care diagnostic tool for detecting self-medication in antenatal care. Although doctors in Western countries can measure the level of antibiotics in the blood, using a rapid blood test (39, 41, 66, 67), this procedure is invasive and requires expensive biomedical equipment and materials (e.g., biosensors and clinical microbiology laboratories) which may be unaffordable in poor countries (68–70). Thus, what is needed is an affordable test that can be easily administered, with minimal technological or resource requirements. Nigerian pregnant women often rely on resource-deprived primary healthcare centres lacking the staff, equipment, and tools to deploy expensive resource-intensive diagnostic tools (71)
Lack of guidelines specific to self-medication during pregnancy was underscored. Current antibiotic stewardship policy focuses on prescribing (37), and there is limited policy guidance on how to manage self-medication (45), including methods for detecting antimicrobial misuse. These policy gaps are evident in WHO policy documents on antibiotic use in LMICs like Nigeria, including the WHO’s Antimicrobial Stewardship toolkit (37). Although some doctors relied on foreign guidelines on antimicrobial stewardship (e.g., RCOG), procedures specific to the Nigerian context may be necessary, given resource challenges, cultural considerations, and other societal constraints prevalent in the region (43).
• Methodological rigour & limitations
This study has several limitations. The sample size and composition are problematic as we only interviewed a limited number of medical doctors, mostly from one tertiary hospital. Furthermore, while Nigerian doctors are a key stakeholder group, exerting considerable influence on health care delivery (44), research suggests most pregnant women in Nigeria, particularly those living in rural areas, have limited access to a doctor (72). Over two-thirds (72%) of pregnant women are cared for by a worker without formal medical training, such as a traditional birth assistant (73). Many pregnant women only visit a health facility (e.g., a rural clinic) in an emergency (72), suggesting medical doctors may have limited opportunity to thoroughly investigate medication misuse. Women who do consult with a doctor are unlikely to share their self-medication habits, due to concerns about disapproval, and other cultural factors (30, 59, 74). Thus, future research needs to interview other stakeholder groups with unique insights on self-medication in pregnancy.
Another possible limitation is the use of a deductive (top-down) theoretical approach to data analysis, driven by the research topic. It is possible that an inductive (bottom-up) approach, driven primarily by the data, rather than a preconceived research theme, would have generated novel constructs not captured by the (rather more conceptually restricted) deductive approach. For example, two minor concepts emerged that didn’t evolve into major themes – one referencing established cultural mindsets on medication use, while the other highlighted the role of independent organisations who supply antibiotics without the need for a doctor’s prescription. It is possible these ideas might have developed into major themes had we used an inductive approach, unconstrained by an a priori focus on specific narratives.
Despite these constraints, the robustness of our findings was confirmed through a series of checks for methodological rigour (Noble & Smith, 2015). First, although the limited sample size has implications for data interpretation, we have been transparent on sample selection, and the methodological justifications used, including saturation, pragmatic considerations, richness, and volume of data, and sample size insufficiency (e.g., generalisability) (46). While recruitment was mostly from one hospital, negating nomothetic generalisability, the data still offers idiographic insights (i.e., captures the unique individual experiences of the doctors), as expected in qualitative research (49).
Second, we conducted meticulous record keeping, in the form of hundreds of email conversations between members of the research team, which documented data collection and analytic procedures. This provided a clear decision trail, ensuring our methods were consistent, and transparent (54). All interviews were recorded using the same software (e.g., Zoom), and stored in the same location (cloud recording), and in similar formats (MP4 and MV4). To enhance accuracy in data interpretation, selected interview recordings, and their transcripts, were reviewed by a researcher not originally involved in transcribing the information, to ensure the recorded dialogue was accurately captured in the transcripts.
Third, we examined differences across interviewee experiences, to ensure conflicting perspectives are considered (55), including concepts mentioned by just one interviewee (e.g., cultural mindsets), and conflicting accounts within themes (e.g., ambiguity regarding the prevalence of herbal self-medication, and at least one doctor had not encountered patients who self-medicate).
Fourth, we performed data triangulation (54), by comparing our findings with outcomes from previous quantitative research (56).This process demonstrated some correspondence, for example the widespread use of medicinal herbs (23).
Fifth, we demonstrated clarity in thought from initial preconceptions to subsequent inferences (57), by assessing how emerging themes compared with our initial suppositions documented in the application for research funding. For example, the lack of policy guidance on antibiotic stewardship in pregnancy, and the need for a practical point-of-care test for detecting self-medication, reflected our initial presuppositions.
Sixth, data collection and analysis were conducted by researchers from four different ethnic backgrounds (Nepalese, Jewish, Nigerian, Indian,), helping reduce cultural bias during the process (57). Two researchers conducted independent checks, to verify initial coding, and emerging themes.
Finally, we conducted respondent validation, to verify the accuracy of emerging themes and identify any points that need correcting or clarifying (54).
• Implications for Safe Motherhood Initiatives
Although the SMI is currently a global priority, with various regional, national, and international strategies implemented to address maternal and child health (12, 13), the implications of maternal self-medication for meeting Safe Motherhood and SDG-3 initiatives in sub-Saharan Africa has yet to be addressed (75). Since medical doctors are an influential stakeholder group (44), with influence on health policy in Nigerian tertiary hospitals (43), their views on maternal self-medication are relevant to meeting SDG-3 targets. The current findings shed light on the scale of the challenge.
Firstly, doctors in Nigeria are keenly aware pregnant women self-medicate with antibiotics, suggesting a readiness to engage with any regional or global SMI campaigns to improve medication safety during pregnancy.
Secondly, a focus on antimicrobial prescribing in Nigerian tertiary hospitals, combined with a lack of clear policy guidelines for managing self-medication, may hamper coordinated campaigns to improve medication safety during pregnancy.
Third, lack of practical point-of-care diagnostic tools to detect and monitor maternal self-medication, in a challenging environment, means Nigerian doctors have no way of collecting baseline data, and tracking changes in antibiotic misuse, over time, to gauge the impact of any SMI initiatives promoting safe motherhood (76–79), and the longer-term impact on rates of birth defects, and maternal, neonatal and child mortality (13). Nigeria currently lacks a coordinated and comprehensive surveillance system on medication safety during pregnancy (76–79).
Fourth, as a concerned stakeholder group, Nigerian doctors can help generate and/or contribute to a regional or international debate on antimicrobial stewardship in pregnancy (43), with particular focus on self-medication (9–11).
Finally, the doctor’s concerns regarding use of herbal medicines during pregnancy necessitates further debate on the potential role of traditional birth assistants in promoting medication safety across the region (80). Data suggest pregnant women in sub-Saharan Africa will not voluntarily share information about their medicinal habits with a trained health professional (e.g., doctor), due to various cultural and religious constraints (e.g., suspicion, distrust) (30, 59, 74). Thus, any viable solution to herbal medicinal use must involve maternity care workers who are trusted by and familiar to the women (81). In sub-Saharan Africa, these workers are usually traditional birth assistants (80).