Accessibility Of Pregnant Mothers To The Health Care Facilities

Project and Seminar Material for Nursing (Science)

Accessibility Of Pregnant Mothers To The Health Care Facilities


This study aims to analyze the Accessibility Of Pregnant Mothers To The Health Care Facilities. Descriptive and multivariate analysis show that the independent variables affect utilization of maternal health services; women who are married, young and rich are likely to utilize maternal health care services compared to women who are not married, older and are poor. Therefore, more effort is needed to be put to educate the general public on the importance of maternal health care services. Moreover, efforts should be channeled to encourage seeking a continuum of maternal health services by pregnant women. Finally, research should focus into understanding the various factors that influence utilization of maternal health care services. The data analysis shows that the most important factors associated with utilisation of maternal health care services are age and marital status.

Chapter One


1.1 Background to the study

Millions of women in developing countries continue to experience serious health problems related to pregnancy or childbirth. Thaddeus and Maine (1990) argued that not receiving adequate care in time is the overwhelming factor leading to death of women in developing countries. The use of health care services is a complex behavioral phenomenon. It is related to the organization of the health-delivery system and is affected by the availability, quality, costs, continuity and comprehensiveness of services; social structure and health beliefs also affect use (Andersen, 1968; Fiedler, 1981; Kroeger, 1983).

Since the International Conference on Population and Development (ICPD) of 1994, reproductive health has taken center stage in population programmes of many countries in the world. In Nigeria, the national maternal health programs include: antenatal care, provider-initiated HIV testing and counseling, skilled attendance at birth, emergency obstetric care, post-partum care and family planning in keeping with national policies.

Hospital-based studies in the world conclude that the majority of maternal deaths are due to one or more preventable direct obstetric complications. Postpartum hemorrhage (PPH) is the most common cause of maternal deaths in sub-Saharan Africa. Other direct causes are puerperal sepsis/infections, hypertensive disorders, obstructed labor/ruptured uterus, and complications of unsafe abortions. Major indirect causes are severe anemia, malaria, HIV/AIDS, and tuberculosis. Also, for every woman who dies, 30 others are maimed by potentially lifelong disabilities such as obstetric fistula.

There are significant variations in maternal mortality levels across and within national boundaries. Globally, an estimated 287,000 maternal deaths occurred in 2010, a decline of 47 percent from levels in 1990. Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85 percent of the global burden (245 000 maternal deaths) in 2010. The global MMR in 2010 was 210 maternal deaths per 100 000 live births, down from 400 maternal deaths per 100,000 live births in 1990. The MMR in developing regions (240) was 15 times higher than in developed regions (16). Sub-Saharan Africa had the highest MMR at 500 maternal deaths per 100 000 live births. Nigeria and India contribute a third of global maternal deaths at 14 percent and 19 percent respectively (WHO, UNFPA, UNICEF and the World Bank, 2009).

According to the UN Interagency maternal mortality estimates, maternal deaths were estimated at 358,000 in 2008. Nearly all maternal deaths occur in developing countries; over 80 percent, with hemorrhage being the most common cause of death, particularly in Africa and Asia. Sub-Saharan Africa which is characterized by rapid population growth, high birth rates and increasing rates of HIV infection, has the highest maternal mortality at 640 deaths per 100,000 live births.

Despite the interventions at national level, countries in Africa still face high maternal mortality. The 2008-09 Nigeria Demographic and Health Survey shows that maternal mortality ratio (MMR) was 488 deaths per 100,000 live births in the country having slightly increased from 414 deaths per 1000 in the 2003 . It is estimated that Nigerian women face a 1 in 35 lifetime risk of maternal death (National Reproductive Health Strategy, 2009-2015) which is the leading cause (27 percent) among women of childbearing age. Conditions during and just after birth cause 9 percent of deaths in the country (MoH, 2010) and thus maternal mortality is a major health problem in Nigeria. According to the UN Interagency report of 2008, Nigeria contributed over 60 percent of maternal deaths in sub-Saharan Africa.

Provinces in Nigeria that have high maternal mortality include Nyanza, Western and Coast (PSRI & UNICEF, 1996). Lagos state is characterized by high levels of fertility, neonatal and maternal mortality rates. The 2008 MoH report shows TFR for Lagos state as 5.6. This means that women are exposed to risks that can be fatal with each pregnancy and delivery.

In an effort to improve pregnancy outcome, the Safe Motherhood Project in Western focused on improving quality of antenatal care, essential obstetric care, clean and safe delivery, post-partum care, post-abortion care and management issues at all levels. In addition, the project also focused on strengthening referral practices and on addressing factors responsible for delays by pregnant women in making decisions on when, where and how to seek care. (Safe Motherhood Demonstration Project Western Nigeria Report, 2004). The Safe Motherhood Conceptual Framework provided the basis for designing the project interventions and overall approach. In addition, use of the three delay model focused the activities in reducing maternal, perinatal and neonatal deaths: (i) delay in deciding to seek appropriate care; (ii) delay in reaching an appropriate health care level; and (iii) delay in receiving adequate emergency care once at a facility. Key issues identified that contributed to high maternal and perinatal morbidity and mortality were: poor referral systems, limited competence and skills among health providers, poor health information system, frequent shortages of essential equipment and supplies, weak management systems at all levels and limited access to basic obstetric care at community level.

Overall, the proportion of women who had heard of a woman dying due to obstetric related complications reduced over the project period. However, despite a reduction in the proportion, a review of maternal deaths records showed that the number of maternal deaths during pregnancy increased at end line. This increase of deaths during pregnancy may indicate more deaths due to abortion complications and probably due to indirect causes such as severe malaria in pregnancy, HIV/AIDS, tuberculosis, cardiac diseases, severe anemia, etc.

The situation regarding neonatal and perinatal health only improved marginally in Lagos state. For instance, 30 percent of women said they had lost at least one child at baseline compared to 28 percent at end line. The age of children who had died was not asked at baseline but among women who had lost a child aged one year or less at end line, 36 percent died within the first month of birth.

The fifth MDG goal is to reduce maternal mortality by three-quarters between 1990 and 2015. To achieve this target, maternal health must be addressed as part of a continuum of care that connects essential maternal, newborn and child health services. Indeed, levels of maternal mortality often reflect the overall performance of a country’s national health system – particularly during delivery and in the postnatal period, when mothers and newborns are most vulnerable. To fill this critical gap, services that benefit both mother and child need to be scaled up, as the health of the mother is closely linked to that of her newborn. However, reducing maternal mortality throughout the developing world is slow and efforts must now be accelerated if the goal is to be reached.

Thus this study seeks to establish the accessibility of pregnant mothers to the health care facilities in Lagos state, Nigeria.

1.2 Statement of the Problem

The 2008-09 it was found that less than half (47 percent) of all pregnant women in Nigeria make the recommended four or more ANC visits. 60 percent of urban women make four or more ANC visits compared with less than half (44 percent) of rural women. The data further show that most women do not receive antenatal care early in the pregnancy; only 15 percent of pregnant women obtain antenatal care in the first trimester of pregnancy; the median number of months at first visit is 5.7 (MoH and ICF Macro, 2010).

Despite high antenatal care attendance in Nigeria, the rate of delivery in a health facility is low. Only 43 percent of live births in the five years preceding the 2008-09 MoH took place in a health facility (KNBS and ICF Macro, 2010).

The 2009 National Reproductive Health Strategy for Nigeria aims to reduce maternal mortality ratio to 147 deaths per 100,000 live births and to increase percentage of women using skilled care in delivery to 90 percent by 2015. When compared to the 2008 MoH maternal mortality rate of 488 deaths per 100,000 live births, this target is yet to be achieved.

Lagos state is characterized by low utilization of maternal health care services despite the various interventions. The community component of the MoH 2010 report shows that women from Lagos state are least likely to deliver in a health facility. It is known that the majority of the maternal and perinatal deaths can be prevented if women received timely and appropriate care.

In Lagos state, the use of skilled health professionals (the use of a doctor, nurse or midwife) during delivery aggregates to 25.8 percent (MoH 2008). The 2007 Reproductive Health Policy recommends having a health worker with midwifery skills during delivery without which there is high risk of maternal death. Comparison of the 2003 and 2008 MoH shows that home deliveries increased from 70.6 to 73.3 percent, indicating low utilization of maternal health care services. Having highest proportions of those who gave birth on their own without assistance in both the 2003 and 2008 MoH report, this proportion increased from 10.6 percent to 14.6 percent. This means that high proportions of births occur at home without the assistance of a skilled birth attendant.

The National Coordinating Agency for Population and Development (NCAPD) identified the relationship between maternal mortality, age, parity, marital status, birth interval, antenatal attendance and occupation as a research gap (NCAPD, 2006). To provide an in depth outlook that will accelerate progress towards improving maternal services, it is important to understand the level of utilization of maternal health care services among women of reproductive age with intention to examine a continuum of care from pregnancy to delivery rather than study the use of one aspect at a time of maternal health.

1.3 Objective of the Study

The aim of this study is to establish the Accessibility Of Pregnant Mothers To The Health Care Facilities in Lagos state. Specifically, the study aims

  1. Determine the demographic distribution of the pregnant women
  2. To investigate the accessibility of pregnant mothers to the health care facilities
  3. To establish factors that determine the utilization of all maternal health care services

1.4 Research Question

  1. What is the demographic distribution of the pregnant women ?
  2. What is the level of accessibility of pregnant mothers to the health care facilities ?
  3. What factors influence utilization of maternal health care services in Lagos state?

1.5 Significance of the Study

Maternal mortality rates in Lagos state remain high and this study aims at contributing to better understanding about utilization of maternal health care services by expectant women in Lagos state. Seeking antenatal services on time by pregnant women helps detect complications and informs mothers on ways to care for themselves and the babies while skilled assistance during delivery decreases both neonatal and maternal morbidity and mortality.

Analysis of patterns of maternal health care utilization behaviour by province is necessary in formulating relevant policies to address provincial differentials in maternal mortality. Therefore, this paper is not only beneficial to women but also policy makers.

A better understanding of the utilization of all maternal health care services will aide in attaining national maternal mortality goals as articulated in various strategies and vision 2030 hence contributing to the achievement of MDGs 4 and 5.

1.6 Scope and Limitation

This study will use data from the 2008-09 MoH which interviewed 8444 women of age 15 to 49, 1039 from Lagos state with a birth in the past five years. The data is retrospective since information is collected in regard to births five years preceding the survey. Therefore, the accuracy of information relies on the ability of the respondent to recall.

Secondary data is limited to characteristics handled in available data. Information on beliefs and practices that would have been included is not available.

In addition, this study focuses on services during pregnancy and at time of delivery. That is ANC services (the number of visits and timing of visits) and the use of skilled delivery. This excludes other maternal health care services such as the use of postnatal care services and family planning. Further, the study does not include information regarding place of delivery which is crucial to maternal and child health.

1.7 Limitation of the Study

Data used in this study is of quantitative nature thus it does not offer explanations to findings in this study. For example, quality of care, cost of transport and distance to a health facility are some of the possible underlying factors in determining the utilizing maternal health care services.

Finally, this study focuses on Lagos state only; therefore, its findings and conclusions cannot be generalized to other provinces in the country.

1.8 Organizations of the Study

The chapter one consist of the introductory part of the study which includes the study background, the statement of the research problem, the study objective and scope of the study.

The second chapter is a critical review of other literatures relevant to the study and its objectives including the theoretical framework for the study. While the third chapter is methods of data collection, sampling and data analysis used in conducting the study. The fourth chapter centres around the research findings including an analysis of how it relates to previous findings. The fifth chapter consists of the summary of findings, conclusion and recommendations base on the study objectives.

Chapter Five

Summary, Conclusions and Recommendations

5.1 Introduction

This chapter presents a summary of the study findings and conclusions, as well as recommendations for programs and research drawn from the findings.

5.2 Summary

The study set out to analyse the accessibility of pregnant mothers to the health care facilities and the association of the selected variables namely maternal age, marital status, highest level of education, type of residence and wealth index.

In order to determine the association between the explanatory variables and the dependent variable, cross tabulations analysis was done and Chi square used as test of significance. On the other hand, to find out the effect of predictor variables on utilisation of maternal health services, multivariate ordinal regression was done.

In this study, the depended variable is a composite index consisting of skilled assistance during delivery, timing of antenatal visits and the number of antenatal visits. Multivariate analysis results indicate that the selected independent variables had influence on the utilisation of maternal health services. The factors have a similar influence on the use of skilled assistance, early antenatal care visits and more than four antenatal visits.

5.3 Conclusion

This study set out to accessibility of pregnant mothers to the health care facilities. It examines health seeking behaviour in reference to seeking a continuum of maternal health care services from onset of pregnancy to delivery, that is, timing of antenatal visits, number of antenatal visits and skilled assistance during delivery.

In this study maternal service is measured with ordered scale and analyzed using ordinal regression model to find the factors associated with the use of maternal services. The ordinal coefficients are interpreted using odds ratio. Bivariate analysis has been used to establish association of independent variables on utilization of maternal health care services.

This study shows that the demographic and socio-economic factors play a role in determining utilisation of maternal health services. The findings of this study therefore confirm the conceptual framework discussed above.
Bivariate analysis results show that while age and marital status are consistently strong predictors in the utilization of all the maternal health services considered in this study, other determinants generally vary in magnitude and level of significance by the type of maternal service- timing and number of antenatal visits, and skilled assistance.

Bivariate analyses of skilled assistance during delivery show that all the independent factors are extremely significant. Age and marital status are significant in determining utilization of all maternal health care services. Wealth and type of place of residence are more significant in determining the timing of antenatal visit than in determining the total number of antenatal visits. Similarly, the highest level of education is more significant in determining the total number of visits than in timing of antenatal visits.

Lastly, women who seek antenatal care on time and have at least four antenatal visits are more likely to use skilled delivery services from health facility.

5.4 Recommendations

5.4.1 Recommendations for programs

The findings show that utilization of maternal health services for Lagos state is very low. Increased efforts should focus on sensitizing the general public on maternal health services and so programs should promote health seeking behavior among women. The health personnel need to be trained about maternal health services and should take part in educating their target populations on the importance of seeking maternal health care services on time.
This study shows that women without education, poor women and those who are not married are less likely to seek maternal health care services. Maternal health programs should therefore be intensified for poor and illiterate women. Programs should be designed to particularly target younger and older women, poor women and those with low levels of education.

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Frequently Asked Questions

Why is access to maternal health services important during pregnancy?

Access to care is vital during this period because it allows providers to identify, treat, and stabilize chronic conditions; address behavioral health needs; and, plan for a healthy and intentional pregnancy. During pregnancy a woman’s need for access to maternal health services increases.

What are the barriers to access to maternal health care?

As with prenatal care, women of color in rural communities face barriers to access including lack of a primary care provider, avoidance of medical care due to cost, and experiences of discrimination and Improving Access to Maternal Health Care in Rural Communities | Issue Brief 11 stigmatization in accessing maternal health care services. 

Why are women in rural areas less likely to access prenatal services?

Women in rural areas are less likely to access prenatal services during their first trimester thanurban and suburban women. This behavior is attributed to less education about the importance of perinatal health, barriers to traveling to care, and a higher rate of unintentional pregnancy.

What is the stigmatization in accessing maternal health care services?

Stigmatization in accessing maternal health care services. 91,92 It is also during this period when most maternal deaths occur. 3.3 After Pregnancy After pregnancy women must reestablish their well-woman care, or in some instances establish care if they did not receive any before pregnancy.

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