Factors Associated With The Use Of Maternity Services
The maternal mortality ratio and other maternal health indicators are worse for developing countries than for the developed world due to improved access to quality care during pregnancy and especially at delivery in the industrialized world. This study was carried out to identify the factors which influenced choice of place of delivery by pregnant women in Enugu, southeastern Nigeria, and to recommend ways to improve women’s access to skilled attendants at delivery. A pre-tested questionnaire was administered by interviewers to women who had delivered within 3 months prior to date of data collection. The response rate was 75.5% (n=1098). Of the respondents, 52.9% delivered outside health institutions and 47.1% in health institutions. The major factors influencing choice of place of delivery included promptness of care, competence of midwife/doctor, affordability, health education, 24 h presence of doctors, team work among doctors and presence of specialist obstetricians.
There were statistically significant associations between choice of institutional or non-institutional deliveries and socio-demographic / economic factors such as place of residence (urban/rural), religion, educational status, tribe, marital status, occupational level, husband’s occupational and educational levels, age and parity (p<0.05). We conclude that factors which will positively influence women to deliver in health institutions in Enugu, Nigeria include a variety of interacting social, economic and health system factors, which operate at various levels-the household, community, the health institutions and the larger social and political environment. Attention to these factors will not only improve maternity utilization but, hopefully, also will reduce the high maternal mortality and improve other maternal health indicators in the study area.
1.1 Background to the Study
The Safe Motherhood Initiative (SMI) was launched in Nairobi, Kenya in 1987 with the goal of reducing maternal mortality globally by half by the year 2000. Available data have shown that the maternal mortality ratios and other maternal health indicators (e.g. percentage antenatal care, percen- tage deliveries in health facilities and percentage skilled attendance at delivery) in most developing countries have worsened instead of improving since the launching of the SMI. In Nigeria, e.g., a study which compared MMRs in a particular institution before and after the launching of the SMI showed a 600% increase after the launching of the SMI compared to before (Okaro et al., 2001). Two very recent studies, which covered six of the 36 states of Nigeria also showed current high maternal mortality ratios in various parts of Nigeria (Fatusi, 2004; SOGON, 2004).
Many reasons have been adduced for this worsen- ing situation of maternal health indicators in Nigeria and range from socio-economic factors through poor infrastructural facilities to poorly organized health systems (Madunagu et al., 2004). Shortly after the launching of the SMI, it was hoped that effective antenatal care would reduce the MMRs in develop- ing countries (Harrison, 1990). However, it became apparent that many women who faithfully attended antenatal clinics ended up delivering in less than ideal places. Those who developed complications were then transferred to hospitals as emergencies. With the realization of the limitations of antenatal care in predicting obstetric emergencies and therefore in reducing maternal mortality ratios, emphasis later shifted to emergency obstetric care (EmOC) as the short-term solution to the high maternal mortality ratio in developing countries. Despite all these measures, the MMRs and other maternal health indicators in Nigeria have remained appalling.
1.2 Statement of the Problem
The organization of health services in Nigeria is such that there is no proper referral system between the primary, secondary and tertiary levels of care (Chukudebelu, 1995). Maternal health care needs to be a linked system operating at different levels and at different points in the reproductive cycle (Roy- ston & Armstrong, 1989). The maternity care situation in Nigeria is such that tertiary care centres take on low risk obstetric cases while primary health centres take on high risk cases which should appropriately be handled by tertiary centres. In other words, in the absence of a proper referral system, parturients who utilize obstetric services deliver in facilities where they should not vis-a` -vis their risk status.
Thus in the absence of a reliable referral system, one improperly understood issue is what determines where a pregnant Nigerian woman delivers. If the factors which guide the decisions on where they deliver are known, these will help in the more efﬁcient organization of maternity services in Nigeria so that both the perceived and actual quality of obstetric care will improve and thereby encourage more women to seek and use available obstetric services. Based on the above, this study seeks to identify the factors associated with the use of maternity services.
1.3 Objective of the Study
The objective of the study includes:
- To identify the factors which inﬂuence the choice of place of delivery by pregnant women in Enugu, South Eastern Nigeria.
- To make recommendations on ways to improve women’s access to skilled attendants at delivery in this community.
1.4 Significance of the Study
At the completion of the study, the findings will be of great importance to policy makers, as the study seek to emphasis on the strategies to improve maternity health care service in Nigeria, the study will also be of importance to the researcher in imbibing a rigorous approach towards examining the challenges of maternity health service.
The study will also be of importance to researchers who intend to embark on study in similar topic as the study will serve as a reference point to the researcher.
1.5 Research Questions
- What are the factors which inﬂuence the choice of place of delivery by pregnant women in Enugu, South Eastern Nigeria ?
- What are the ways to improve women’s access to skilled attendants at delivery in this community ?
1.6 Scope and Limitation of the Study
The scope of the study covers an assessment of factors which inﬂuence the choice of place of delivery by pregnant women in Enugu, South Eastern Nigeria. But in the cause of the study, there were some factors which limited the scope of the study;
(a) Availability of Research Material:
The research material available to the researcher is insufficient, thereby limiting the study.
The time frame allocated to the study does not enhance wider coverage as the researcher has to combine other academic activities and examinations with the study.
The finance available for the research work does not allow for wider coverage as resources are very limited as the researcher has other academic bills to cover
Conclusions and Recommendations
It was concluded that factors that will positively inﬂuence women to deliver in health institutions in Enugu, Nigeria include a variety of interplaying social, economic and health system factors, which operate at various levels—the household, community, the health institutions and the larger social and political environments. Based on the ﬁndings in this study, we recommend government subsidy of the delivery fees and/or health insurance premium of poor women of reproductive age, training and retraining of maternity care staff in order to increase their competence and updating of equipments in the health facilities. Attention to these factors will not only improve maternity utilization but will also, hopefully, reduce the high maternal mortality ratios in the area.
Limitations of the Study
This study has some limitations. Since it was a questionnaire-based, the responses may not have reﬂected the true opinions of all the respondents. Again since some of the respondents were not educated, there might have been varied under- standing of the questions by such respondents following interpretations to the local language by the interviewers. The study was designed to analyze factors associated with utilization of maternity services in Enugu and may not be representative of the whole of Nigeria with its diverse socio- cultural and demographic settings. In the current paper the inﬂuence of the medical, obstetric and gynaecological complications noted in the some of the respondents on their choice of place of next delivery was not analyzed.
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