This study was designed as participatory research using the HCD through co-research, co-design, and co-refinement phases involving desk reviews, interviews, brainstorming, and rapid prototyping. The aim was to identify and develop facility-level solutions to strengthen the appropriate use of uterotonics for PPH prevention and treatment, reduce gaps in maternal health services, and drive improvements in uterotonic use for PPH prevention and treatment in Kano, Lagos, and Niger states in Nigeria through the development and integration of solutions to achieve a safe pre- and post-childbirth delivery experience for women in Nigeria.

This study was guided by the principle that the quality of PPH care spans the entire lifecycle of the uterotonic administration, beginning from production to proper usage within the hospital setting. It recognizes that people play a pivotal role at every stage of this process and emphasizes the importance of understanding the system to facilitate necessary improvements for better outcomes.

The data collection and synthesis involved incorporating the principles of HCD. This is a user-inclusive approach that has been adopted to address and proffer customized solutions to complex challenges that impact the public health space, as well as suit the beneficiaries of the solutions [16]. It entails a mindset that starts with the people for whom the intervention is designed and ends with new solutions that are tailor-made to suit their needs. This approach disrupts traditional methods where researchers, health care providers, and administrators design new care models based solely on studies and expert opinions, instead integrating health care users’ perspectives across all stages of the process [17-19].

The HCD process used in this study included co-research, co-design, and co-refinement phases (Table 1). Each of these phases enabled the discovery and an understanding of the problem and allowed us to co-create and test the developed solutions using iterative processes (Figure 1).

The co-research phase was conducted across the 3 program states—Kano, Lagos, and Niger—from May 24 to October 24, 2022. It kick-started the HCD process and involved identifying the knowledge gaps around maternal mortality due to PPH through desk reviews to (1) understand the current status of PPH in Kano, Niger, and Lagos states; (2) frame research questions; and (3) design the data collection. The insights gleaned from this phase were subsequently translated into opportunities for impact.

The co-design phase was conducted across the 3 program states from November 7, 2022, to January 10, 2023. The co-design phase aimed at transforming insights that were identified during the co-research phase into new and more structured ideas via the brainstorming process, which encouraged the champions to think expansively.

The co-refinement phase took about 1 month to achieve between January 2 and February 23, 2023. During the co-refinement phase, each of the context-based solutions was validated through rapid prototyping.

In the co-research phase, 58 champions were trained in data collection across these 3 states. Training on proper interviewing techniques and mock sessions were held across the states. This enabled the government stakeholders from the program State Ministries of Health and the State Primary Health Care Boards, assigned as HCD champions, to review existing knowledge, identify gaps, and define the research methodology needed to deepen understanding of the problem.

The methodology for data collection was selected based on the timeframe, understanding of the local context, and resources available. The following exploratory methods were selected: (1) site visit observation (live-birth observation); (2) interviews with key informants (government officials); and (3) one-on-one interviews with pregnant women, health care providers (ie, nurses, midwives, doctors, and other health professionals), traditional birth attendants (TBAs), or health facility representatives (ie, facility in-charges and administrators).

The data collection tools were developed based on identified gaps from the landscape review and to answer the research question on these core areas: facility profile, knowledge and information on the use of uterotonics, the types and challenges regarding uterotonic use, facility equipment, and uterotonic availability.

Three unique tools were developed to solicit responses from the participants: (1) an observatory tool for the site visit (health facilities); (2) key informant interview guides; and (3) survey tools for health care providers, TBAs, and pregnant women. These tools differed for each group, ensuring the questions were tailored to their various contexts.

A 3-day workshop was organized in each of the 3 program states to gather the data collected from the field activities. This workshop focused on identifying the knowledge gaps gathered, having a clear and robust understanding of the challenges to be addressed, as well as generating insights to be translated into areas for opportunities.

The data collected (site visit observation, interviews with key government informants, and one-on-one interviews with pregnant women, health care providers, TBAs, or health facility representatives) were analyzed using a descriptive analysis method to constructively summarize data points.

Data analysis followed three steps in accordance with the HCD methodology: (1) identifying key themes from the collected data, (2) developing “insight statements” that encapsulate these themes, and (3) translating each insight statement into actionable “design opportunities” [16,20]. The synthesis and actionability of the findings from the co-research phase were carried out in the co-design and co-refinement phases.

The co-design phase featured a 2-day workshop in the program states where the HCD champions collectively brainstormed over 60 unique ideas from individual concepts and bundled them into 12 distinct robust prototypes of substance that were best suited to address the challenge. In the co-refinement phase, the solutions (prototypes) were tested with the intended users, and their feedback was integrated. This involved redoing, discarding, and refining the solutions based on a rich understanding of the context, and many potential points of failure that have been uncovered and resolved. Following the testing and feedback activity, the most viable solution was selected, one for each state, and a plan of action was created for implementation on a larger scale. These co-design and co-refinement processes were iterative to ensure the most appropriate models were achieved.

The study was carried out between May 24, 2022, and February 23, 2023, and was conducted in strict compliance with the ethical standards outlined in the Helsinki Declaration, ensuring the well-being of the participants. These standards encompassed obtaining informed consent, guaranteeing confidentiality, and safeguarding participants’ rights. Prior to commencement, the research received its ethical approval from the National Health Research Ethics Committee of Nigeria (NHREC) under the approval number NHREC/01/01/2007-15/03/2022 on March 15, 2022.

In total, 203 interviews were conducted among 97 health care providers, TBAs, and CHIPS (Community Health Influencers, Promoters and Services) Programme agents; 80 pregnant women or nursing mothers; and 26 government officials, with observations conducted at 33 sites across a 3-level continuum of care. Table 2 presents the participant distribution across the states.

The findings were classified based on the 3 HCD phases used in this research. Following the analysis of the data collected in the field during the co-research phase, the strong findings were subsequently categorized under common themes according to the different participant groups as described in Table 2. The findings were further synthesized into insights that were translated into opportunity areas for impact in the co-research phase.

All of the activities in the co-research phase ensured a robust and clear understanding of the challenge to be addressed. The key insights from the co-creation phase across the 3 program states included the challenges faced by pregnant women in rural areas concerning affordability, accessibility, and awareness of health care services; health care workers’ strong commitment to maternal health despite issues with service efficiency and working conditions; observations indicating inadequacies in equipment and space management within health care facilities; and key informants expressing concerns about the current health care system’s ability to deliver adequate maternal care, emphasizing the need for ongoing improvements in service delivery and coordination.

The workshop focused on finding solutions to the challenges from the findings from the co-research phase. These solutions aimed to provide improvements in clinical care and appropriate use of uterotonics for PPH management and treatment.

During the co-design session, ideas and concepts were synthesized, reviewed, and narrowed down to a set of concepts that could be developed for testing. The main components of this phase were framing the design challenge, generating “how might we” questions to proffer solutions to the identified challenge area, brainstorming ideas, creating appropriate storyboards for promising solutions, and conducting rapid prototyping sessions. In this phase, over 100 different ideas were submitted by champions across the various states to resolve the identified challenge statement.

The co-refinement phase comprised 2 stages to contextualize the prototypes developed from the co-creation phase (Figure 2). In the first stage, 12 initial prototypes were carefully evaluated for their suitability to address the state-specific issues and narrowed down to 5 prototypes with the most promising qualities. These 5 prototypes underwent further evaluation in the second co-refinement stage to produce 3 prototypes, one for each state, that best addressed the specific issues related to optimizing uterotonic supply chain systems and health service delivery in managing PPH.

While much of the global effort has focused on a health system–strengthening approach to reducing pregnancy-related deaths in low- and middle-income countries [21,22], less energy has been focused on solutions that take into consideration the major challenges mothers go through during pregnancy, so as to develop a client-centered solution that effectively addresses their needs. This research was aimed at proffering solutions to develop context-specific solutions to enhance service delivery for postpartum care in Lagos, Kano, and Niger states using HCD.

In the co-discovery phase, the study was able to uncover critical challenges faced by both pregnant women and health care workers in rural settings, with a focus on maternal health care access and service delivery. Pregnant women primarily struggle with affordability, accessibility, and awareness. Many of these women are housewives in rural areas, with limited financial resources and logistical difficulties in accessing health care facilities [23]. These findings are consistent with existing literature, which highlights that rural women often face significant socioeconomic barriers, including poverty, transportation challenges, and limited access to health care services [24-26].

Health care workers, on the other hand, are very committed to improving maternal health but face challenges resulting from gaps in care levels between primary and secondary facilities. The strain is particularly evident in facilities with high client volumes and limited human resources [27,28], underscoring the need for better support systems for health care providers in these settings. There were also issues of inadequate health care infrastructure, such as insufficient storage systems and overcrowded delivery wards, which could compromise the quality of care provided during critical moments like prolonged labor [28,29]. There is also the issue of the service delivery system, which requires continuous strengthening to meet the needs of these vulnerable populations. Addressing these issues will require a multifaceted approach, which should include a better system for managing the human resource problems, improved health communication strategy, demand generation, and enhanced coordination of care to ensure that both health care workers and pregnant women receive the support they need to achieve better health outcomes [11].

In this research, the co-design phase was aimed at synthesizing relevant questions to create potential solutions for the identified problems affecting the appropriate use of uterotonics and PPH care, particularly in resource-limited settings. This process highlighted the importance of involving the intended users in the HCD co-design process to ensure that the developed solutions are tailored to the specific contexts and challenges identified [30,31]. For instance, the HCD co-design phase was used to develop health solutions to enhance the comfort, health outcomes, and overall satisfaction and experience of patients [16,32].

More than 100 questions and ideas gathered from the initial co-research phase were ideated in brainstorming sessions to identify the 12 most feasible prototypes. These solutions were narrowed down by selecting the questions that most exhaustively discussed the challenges with service delivery for PPH care, suited the contexts in each state, and considered the most frequently occurring challenges and issues. This was done to ensure the final prioritized questions would generate solutions that would incite the most impact in each state. The brainstorming approach to co-design was used to further foster creative thinking and ideation, as well as generate comprehensive, user-centric solutions [16,33]. The 12 prototypes were further refined to select the most fitting solutions for the 3 states.

The implementation of brainstorming sessions in the co-design phase aided the co-refinement of the 12 prototypes. The collaborative relationships built during this session fostered the iteration and feedback process, ensuring that the prototypes selected aligned with the needs of the users and were actionable and sustainable [33,34]. The 12 prototypes were narrowed down to 3 final solutions, which were selected based on their operationalizability (how well they worked), feasibility (how possible it is to implement), and specificity (how they matched each state’s unique challenges).

The study has successfully applied HCD to develop unique solutions capable of strengthening clinical care, reducing gaps in the delivery of maternal health services, and driving improvements in the use of uterotonics for PPH prevention and treatment using statements generated from the co-research and co-design phases. The study objective of developing facility-level solutions for optimizing uterotonic supply chain systems and health service delivery in PPH management was achieved through the creation of solutions that were able to increase the demand for ANC services among pregnant women and their families, particularly their spouses, improve the storage and supply of uterotonics, and generate equitable distribution and improved capacity of health care workers to handle PPH. Although the designed solutions do not address all the issues raised, their implementation can strengthen an evidence-based approach to maternal and child health services and, in turn, improve PPH management. This implementation phase will involve deploying the uptake building of the solutions and documentation outcomes, building a comprehensive picture of the entire process, and identifying potential points for intervention.

First, this study was conducted in only 3 states within Nigeria, indicating that the developed solutions may not be applicable in other regions with different cultural, socioeconomic, and health care contexts. Second, it focused on proffering solutions to improve uterotonic supply chain systems and health service delivery in PPH management, overlooking other critical aspects like cultural and religious beliefs, as well as the quality of care. Third, the short timeframe of the study and the lack of implementation mean that the long-term outcomes or effectiveness of the solutions were not captured.