Study design

This is an exploratory, qualitative implementation study using framework analysis. The study was conducted within the Implementation Research for Intravenous Iron Use in Pregnant and Postpartum Women in Nigeria (IVON-IS) project [19,20]. The IVON-IS project was a multi-site implementation study conducted in Lagos, Nigeria, aimed at evaluating the feasibility, acceptability, and effectiveness of introducing IV iron (FCM) as a routine treatment option for pregnant and postpartum women with moderate to severe anemia [20]. We report this study following the consolidated criteria for reporting qualitative research (COREQ) (S1 File) [21].

Study setting

The study was conducted in Nigeria, a country characterized by significant diversity, encompassing 36 states, a Federal Capital Territory, 774 local government areas, over 400 ethnic groups, and approximately 450 languages across its six geopolitical zones [22]. The Nigerian health system is delivered across three tiers: primary, secondary, and tertiary. This study was conducted in a cluster of six healthcare facilities as part of the IVON-IS project in Lagos State, South-West Nigeria [20]. The facilities included one tertiary hospital (Federal Medical Center Ebute Metta – designated as TF); two secondary hospitals (Harvey Road General Hospital – SHF1 and Ebute Metta General Hospital – SHF2); one comprehensive primary healthcare center (Akerele Health Center – designated as PHC); and two private hospitals, Havana Specialist Hospital – PHF1 and Kensington Adebukunola Adebutu Foundation (KAAF) Maternity Hospital – PHF2. These facilities were purposively selected to represent different levels of the Nigerian healthcare system while maintaining geographic proximity within the state’s established referral network. The selected healthcare facilities collectively serve a diverse patient population. providing prenatal and postnatal care services to women from various socioeconomic and cultural backgrounds. Patient coverage and services differed across the selected healthcare facilities. The PHC patients were approximately 40–45 pregnant women weekly for antenatal care; however, postnatal services were not yet operational when the study began. Weekly antenatal visits at the first secondary centre (SHF1), was averaged 93 pregnant women weekly for antenatal care. The other secondary centre (SHF2) averaged 15–20 pregnant women, while postnatal visits averaged five women per month. The tertiary hospital (THF) provided services to approximately 100 pregnant women and 10–20 postnatal women each week. Regarding the private clinics, PHF1 accommodated between 38–44 pregnant women and 10–15 postnatal women at their weekly clinics. PHF2 averaged 25 antenatal and 15 postnatal women weekly.

Recruitment procedure

We aimed for a sample size that considered information power based on the study aim, sample specificity, involvement of different cadres of SHPs across various health facilities, and the high quality of dialogue from multiple perspectives [23]. We employed a purposive sampling technique to identify skilled healthcare providers involved in the IVON-IS project, who were then recruited for this study. We invited 18 SHPs, three from each facility, and none declined. Of the 18 recruited SHPs, 13 were physicians and five were nurses, across the six implementing health facilities. SHPs are defined as competent maternal and newborn health (MNH) personnel who can provide effective, uninterrupted, high-quality care [24].

Data collection

Three trained interviewers facilitated key informant interviews (KIIs) with SHPs involved in the IVON-IS project. KIIs were selected as they provided opportunity for in-depth discussions and are practical for healthcare providers [25]. Each interview involved two team members, one to conduct the interview and another to monitor and record.

The KIIs were conducted with semi-structured topic guides. The guides were developed using NPT constructs while allowing for emergent themes. Interview questions explored providers’ understanding of IV iron’s purpose and benefits (coherence); their willingness to adopt IV iron and factors motivating participation (cognitive participation); workflow integration and resource allocation processes (collective action); and evaluation methods and sustainability planning (reflexive monitoring).

Interviews were conducted in English at the six health facilities between October 23 and December 5, 2024 (Table 1). Each interview lasted between 30–45 minutes. Topic guides were piloted prior to data collection, using similar participants and adjustments made for clarity. All interviews commenced after obtaining consent from participants. All interviews were audio-recorded with participant consent and transcribed verbatim.

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Table 1. Summary profiles of participants interviewed.

https://doi.org/10.1371/journal.pone.0337162.t001

Theoretical framework

This study is grounded in the Normalization Process Theory (NPT), which views healthcare practices as fundamentally social phenomena constructed through collective work rather than implemented through top-down directives [26,27]. The NPT’s ontological position acknowledges that IV iron implementation entails complex negotiations among healthcare providers, organizational contexts, and existing care practices, thereby positioning implementation as an emergent social process rather than a predetermined technical pathway. The NPT adopts a constructivist approach that prioritizes healthcare providers as active agents who interpret, adapt, and sustain new practices within their respective contexts. This aligns with our research objectives to understand how providers make sense of IV iron, engage with its implementation, and operationalize it within existing workflows. The NPT examines normalization through four core constructs: Coherence (how individuals understand the intervention and differentiate it from existing practices); Cognitive participation (how individuals commit to and engage with the intervention); Collective action (how the intervention is operationalized through coordinated work); and Reflexive monitoring (how individuals evaluate and refine the intervention). The NPT’s focus on these normalization processes is particularly relevant for resource-constrained settings, where successful integration requires fundamental shifts in how maternal anemia care is conceptualized and delivered through coordinated efforts across multiple levels of the healthcare system [26,27.]

Data analysis

The NPT framework was used to inform and guide the analysis. During data analysis, the four NPT constructs (coherence, cognitive participation, collective action, and reflexive monitoring) served as initial coding categories, with subcategories developed inductively from the data. This approach facilitated a systematic examination of implementation processes while remaining open to context-specific factors that might not be explicitly captured by the theory. The analytical process involved mapping participant responses to NPT constructs, identifying patterns across facilities, and exploring relationships between theoretical components to understand how IV iron became normalized (or faced barriers to normalization) within the healthcare settings. Next, two qualitatively trained researchers (DO and EE) randomly selected two transcripts and coded them independently. The codes were discussed, and a final coding framework was developed. EE then coded the remaining data. All codes were subsequently organized into categories, after which key themes and sub-themes emerged from the data [28]. Analysis was conducted iteratively, with researchers identifying themes related to each NPT construct and examining the relationships between these themes to understand the overall normalization process. NVivo 12 Plus (QSR International, Memphis, USA) aided analysis.

Ethical declarations

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in (S3 File).

Coherence: Making sense of IV Iron

The SHPs demonstrated a strong understanding of IV iron’s purpose, benefits, and differences compared to traditional treatments for anemia. This understanding evolved from initial uncertainty to clear conceptualisation throughout the implementation process. Providers conceptualised IV iron as both a treatment option and an innovation in maternal healthcare delivery, frequently describing it as a “novel method of treatment” for reducing the burden of moderate to severe iron deficiency anemia. As a male SHP articulated,

“It serves to reduce the burden for iron deficiency anemia among pregnant and postpartum women who have moderate to severe anemia.” Senior Medical Officer, Male, SHF2

The SHPs differentiated it from existing practices, primarily emphasizing its key advantage of single-dose administration versus daily oral medication.

“The previous method [oral iron] involved women taking medication every day; meanwhile, administration of IV iron involves administration of a single dose of iron.”

This understanding was consistently echoed by SHPs across different facilities.

“The purpose of using IV-ion for maternal anemia is to help correct moderate to severe anemia in order to improve maternal well-being and also foetal well-being too... So that the mother can have an optimal blood level, in other words, an optimal haemoglobin level during pregnancy and even immediately after delivery.” Medical Officer, Male, PHC

Multiple benefits were identified by the SHPs that reinforced IV iron’s value in clinical practice, including improved patient compliance, efficacy for patients with asymptomatic severe anemia, and reduced treatment burden. Providers also recognized broader socioeconomic benefits, particularly the cost savings for patients who might otherwise require blood transfusion at secondary facilities.

“The main purpose is to reduce anemia in pregnancy and postpartum women, and it has been very, very helpful because if they are being referred to the secondary facility they need to pay for blood transfusion, they need to pay for some other logistics but here the purpose was fulfilled it is free, its safe and it is accessible.” Chief Nursing Officer, Female, PHC

This comprehensive understanding of purpose, distinctiveness, and benefits created a strong foundation for implementation.

Cognitive participation: Engaging with IV iron implementation

The analysis revealed varying engagement levels among SHPs with important insights into motivational factors and the role of key individuals in driving adoption. Leadership support emerged as a critical facilitator, with facility management creating an enabling environment for the intervention.

“We benefitted from the buy-in from management... the fact that the medical director, we had the full support of the medical director, it really helped.” Senior Medical Officer, Male, SHF2

This support was operationalized through Implementation Management Teams (IMTs) that coordinated activities, conducted regular monitoring, performed data analysis, and produced reports. Within each facility, specific local champions drove implementation forward by maintaining momentum and addressing challenges. IMT members were compensated for their time with an honorarium after their regular meetings. A nurse midwife described this leadership involvement:

“Our apex nurse is part of the IMT... And our Medical director, too, was aware of it... So, they all supported.” Chief Nursing Officer, Female, PHC

Staff engagement varied considerably across facilities and over time. Initial resistance gradually evolved into acceptance as SHPs became more familiar with the intervention. The implementation typically followed a pattern of gradual adoption, characterized as “slow initially” but eventually becoming “seamless” after persistent counselling and education efforts. Several factors motivated SHPs’ engagement, including professional interests, personal values alignment, and financial incentives, which proved especially important for lower-cadre staff. Despite these varied motivations, patient benefit consistently emerged as the primary driver of engagement. As a female nurse emphasized,

“My patient is going to benefit much from it... so that’s one of the main reasons.” Assistant Director of Nursing Services, Female, SHF2

“The factors that motivated us to say ok, let us find a lasting solution to this If IV-ion is the solution, then let’s go ahead and use it to treat maternal anemia.” Medical Officer, Male, PHC

According to the SHPs, the patient-centred motivation helped sustain commitment when implementation challenges arose.

Collective action: Operationalizing IV iron use

SHPs described how IV iron was integrated into existing practices, including workflow adaptations, resource utilization, and addressing implementation challenges. Clinical workflow integration required significant adaptations, including securing an appropriate physical space for administration and modifying screening protocols to test all antenatal patients for anemia on a routine basis.

“Now we routinize the screening so all ante-natal patients are now tested for anemia because we are trying to be on the lookout for those that have moderate or severe anemia.” Medical Officer, Male, SHF1

Furthermore, the SHPs emphasized that integrating IV iron into existing workflows necessitated a coordinated effort across multiple units and leveraging existing meeting structures.

“We have the pharmacy, we have the Lab, we have the Nurses, we have the Doctors. We all work hand in hand. If there are any challenges, we have a meeting every month. We discuss our challenges, what ways we can use to improve, and assist with the project... Everybody has their own role to perform.” Consultant Obstetrician and Gynaecologist, Female, SHF1

Staff roles were redistributed, with specific responsibilities assigned for screening, consent processes, and administration. Physicians typically assumed primary responsibility for IV iron administration, creating new collaborative arrangements that required coordination among diverse SHPs.

Resource availability significantly facilitated implementation, with providers highlighting the importance of having appropriate equipment and supplies. This resource provision minimized logistical barriers to implementation. One male provider noted,

“Everything was in place from the HemoCue to diagnosis; quickly, we were able to map out processes to make it work in this facility.” Medical Officer, Male, SHF1

Despite careful planning, several implementation challenges emerged. Staffing constraints affected service delivery, with the additional workload impacting existing clinical duties. A female provider described this impact:

“It affected my daily work routine because it makes me leave the patient I am attending to, whether in the gynaecology clinic or the antenatal clinic.” Assistant Director of Nursing Services, Female, PHF2

This was echoed by a nurse midwife who noted

“It has affected my work routine mostly because of the ‘japa’ [brain drain]; most of the nurses have travelled out [of the country], so the workload is much. At times, the doctors might be busy downstairs. We need to pick their line and set their lines for them.” Chief Nursing Officer, Female, PHC

Space limitations and logistical issues also presented obstacles that required creative problem-solving.

Patient acceptance challenges were also noted, particularly related to the intervention’s novelty, with literacy levels and communication barriers complicating patient engagement. A medical officer shared:

“Only one patient complained that she didn’t want IV iron. We counseled her, and she said No. And then I think we tried to speak with the husband, but we couldn’t get through to him. That was the only patient I know of that declined the infusion.” Medical Officer, Female, PHC

Reflexive monitoring: Evaluating IV iron implementation

SHPs continuously assessed IV iron’s effectiveness, addressed emerging issues, and gathered patient feedback to refine the implementation process while considering sustainability challenges.

Some SHPs reported that they primarily measured effectiveness by tracking clinical outcomes, especially improvements in hemoglobin levels. Some providers noted discrepancies between expected and observed clinical responses, with hemoglobin levels sometimes taking longer to rise than anticipated. As one male stated:

“We were expecting that within two to three weeks we should start seeing the rise, but most times we don’t even see any rise at all till the third and fourth week.” Medical Officer, Male, SHF1

These observations prompted adjustments to patient counselling regarding expected outcomes.

SHPs stated that regular evaluation meetings facilitated continuous quality improvement through systematic bottleneck analysis and data-driven decision-making.

“We usually have meetings to analyse for bottlenecks... so that we could identify the challenges and how to overcome them.” Doctor, Female, TF

Implementation teams used these processes to identify and address emergent issues, including knowledge gaps among new staff and clinical errors, which became learning opportunities.

Patient feedback was generally positive, regarding the intervention.

A nurse midwife noted:

“They are always very happy o! They come back saying thanking us, ‘nurse thank you o’; and the good thing was that it was free. They are so happy because they don’t have to pay for it.” Nurse Midwife, Female, PHF1

This appreciation extended to word-of-mouth promotion among patients and positive reception of comprehensive anemia screening. One SHP described:

“They are happy, they want to tell their other friends, ‘Go to that hospital, they will give you’. You know, because we attend to a lot of semi-literate, let me say that, so when they come and they see good outcomes, they want to bring their friends. “Medical Officer, Male, PHC

Despite the successful implementation, participants expressed significant concerns about the long-term sustainability, particularly regarding access to the IV iron after the project end. A medical director voiced this anxiety:

“My greatest fear now is that now that project is rounding up... I don’t know if we will still have access to some of these drugs.” Medical Director, Female, PHF1

A nurse midwife similarly expressed concern

“When the project was on, it has been our routine care, but now that the project has stopped and no [more] support, how do we do it? I cannot use my salary to buy the injection. I cannot use my salary to buy all the consumables.” Assistant Director of Nursing Services, Female, PHF2

SHPs demonstrated proactive engagement with sustainability planning through institutional advocacy efforts and proposing potential solutions focused on resource availability and cost reduction strategies. A medical officer described their efforts:

“Now we are trying to have a meeting with the Medical officer of Health, that is the head of the clinical service in the local government, and then the other stakeholders like the special adviser on health and some other stakeholders in the health department of the local government, in addition to primary health board to see if there can be some kind of incentives and support.” Medical officer, Male, PHC

Suggestions for sustaining the intervention included seeking Non-Governmental Organisation (NGO) sponsorship, implementing a drug-revolving system with government subsidies, and incorporating patient co-payments. These sustainability planning efforts underscore the providers’ commitment to maintaining IV iron as part of routine care, despite the challenges of transitioning from a donor-supported project to a self-sustaining program.

Strengths and limitations

The use of the NPT offered the possibility to understand how a new intervention, IV iron, was instutionalized in the health facilities from the perspective of SHPs. In addition, the sample size recruited for the study, the appropriateness of which was assessed with the principle of information power, offered us an opportunity to have comprehensive narratives that enabled data and analytical sufficiency. Additionally, to enhance trustworthiness, a transparent process was maintained throughout the study, and a rigorous analytical approach was employed to ensure credibility and promote reflexivity. Despite these strengths, our study has some limitations. The first significant limitation of this study is its qualitative design and intentionally bounded geographical and population focus. While qualitative inquiry is well suited to exploring complex phenomena in depth, it inherently limits the generalizability of findings. In this case, the research was conducted exclusively within Lagos State, Nigeria, which may not fully capture the diversity of health-system structures, resource constraints, or sociocultural dynamics present across other regions of the country. These constraints necessitate caution when interpreting the results or extrapolating them beyond the study context. Despite these limitations, the study offers important and contextually grounded insights into the institutionalization of intravenous iron for pregnant and postpartum women in Nigeria, shedding light on both the opportunities and challenges that accompany efforts to integrate this intervention into routine maternal healthcare.

Secondly, the study relied on KIIs with SHPs, potentially missing perspectives from patients and health system administrators. Thirdly, our data collection occurred during the active implementation phase, and we were unable to assess the long-term sustainability of the intervention beyond project completion.

Recommendations for implementation

Based on our findings, we propose the following recommendations to facilitate the successful implementation of IV iron in similar resource-constrained settings:

1. Develop comprehensive educational materials: Create educational resources for both SHPs and patients that clearly explain IV iron’s mechanism of action, benefits, and expected outcomes. These materials should address common misconceptions and set realistic expectations regarding the timeline for hemoglobin improvement.
2. Secure early leadership engagement: Formally engage facility leadership from the planning phase to establish champions who can facilitate institutional buy-in. Leadership should be involved in creating dedicated implementation teams with clear roles and responsibilities.
3. Perform pre-implementation workflow analysis: Before introducing IV iron, conduct a detailed analysis of existing clinical workflows to identify potential integration points and resource needs. This should include space allocation, staffing requirements, and scheduling considerations to minimize disruption to existing services.
4. Establish structured monitoring systems: Implement regular data collection and review procedures to track clinical outcomes, patient experiences, and implementation challenges. This should include standardized documentation tools and scheduled review meetings to address emerging issues promptly.
5. Develop sustainability planning from inception: Create sustainability plans at the outset that address long-term financing, resource procurement, and integration into existing health system structures. Engage with policymakers early to advocate for inclusion of IV iron in national guidelines and essential medicine lists.
6. Design tailored training programs: Develop role-specific training that addresses not only technical aspects of IV iron administration but also strategies for patient counseling, consent processes, and management of potential adverse effects. Training should be ongoing to accommodate staff turnover.
7. Establish clear communication channels: Create formal communication structures between different cadres of SHPs involved in maternal anemia management to ensure coordination and information sharing about patient care.
8. Frame intervention around patient benefits: Emphasize concrete patient benefits when communicating about IV iron to healthcare workers to leverage patient-centered motivation as a driver of engagement.
9. Explore innovative financing mechanisms: Investigate approaches such as drug revolving funds and public-private partnerships to ensure financial sustainability beyond the initial project funding.