Patterns Of Utilization Of Maternal Health Services In Primary Health Care Facilities
Women in most parts of Niger State face constraints in obtaining and utilizing quality maternal health services. This study was carried out to identify the availability, quality and patterns of utilization of maternal health services in Primary Health Care (PHC) facilities in Niger State, Nigeria. Utilizing the cross-sectional survey design, the political economy and the Health Belief Model theoretical perspectives, data were collected from 903 women of childbearing age, 69 married males and 24 maternal health care providers in 24 Primary Health Care centres located in six Local Government Areas in the state.
The women of childbearing age were selected through a combination of cluster, systematic and purposive sampling techniques while the married males were selected based on availability and willingness to participate. The Primary Health Care facilities and the maternal health services providers were selected based on their location and service provision in the selected study communities. Data were obtained from the women of childbearing age through the questionnaire. In-depth interview and focus group discussions were utilized to collect data from the maternal health services providers and married males in the study communities respectively. Primary Health Care facilities were assessed with the aid of a United States Agency for International Developments‟ adapted maternal health services evaluation tool. In addition, focus group discussions elicited information on perceived causes of maternal health problems, maternal health behaviour of mothers and men‟s responsibilities in maternal health care.
Findings revealed that most of the PHC centres were dilapidated. Some of the roofs were blown off and leaking, while the doors, windows and floors of some PHC clinics were damaged. There was shortage of medical equipment, consumables and drugs for basic maternal health services. Most of the clinics (75%) had only low level trained health personnel like Community Health Extension Workers and Environmental Health Officers as only six clinics had trained midwives provided through the Midwifery Service Scheme and the SURE-P programmes of the Federal Government. It was observed that the available facilities were poorly managed while the 2-way referral system was poorly implemented and in some instances non-existent. Similarly, there was poor community participation in the health facility management. More than 90% of the women of childbearing age were 18-41 years old, 84.9% had 1-4 children and only 44% practiced family planning.
From the findings, 33.7% had no formal education and 15.8% had only primary education. Similarly, 29.7% and 10.3% of their husbands had no formal education and primary education respectively. Women and husbands‟ level of formal education was found to have influenced the utilization of maternal health services by women. Prolonged labour (19.3%), hypertension in pregnancy (18.9%), bleeding in pregnancy (12.6%), anaemia (11.5%), postpartum haemorrhage (8.8%) and retained placenta (6.8%) were common maternal health problems reported by women during their most recent pregnancies. Some women (3.3%) required 3-5 hours of walking to reach the nearest Primary Health Care centre and only about 50% always get attended to in the clinics. Provision for emergency obstetrics care (EmoC) was non-existent in most Primary Health Care facilities. Although most women utilized the antenatal care services (83.1%), only 60.5% delivered in the clinics. Very few utilized the postnatal, family planning and immunization services because many felt that these services are not necessary. Injectable contraceptives were the commonly utilized method of family planning.
Although husbands usually pay for services utilized by their wives and occasionally gave other supports for services utilized, their consent was a strong condition for service utilization by women. Most women attended the antenatal clinics more than the recommended four times because of the health workers‟ inadequate knowledge of the new approach. Younger women utilized maternal health services more than the older women. Male dominance had significant impact on maternal health service utilization as most women required the permission and financial support of their husbands for service utilization. Similarly, ability to pay for maternal health services significantly influenced utilization of the services. Women who were gainfully employed utilized the services more than those not gainfully employed on account of their economic strength. It is therefore recommended that actions should be taken by members of the community, government and non-governmental organizations to renovate Primary Health Care facilities.
The facilities should be adequately supplied with basic medical equipment, consumables and drugs to improve service delivery. The State and Local Governments should employ and equitably distribute more midwives Primary Health Care facilities to improve the quality of services at various levels of care. Also, public enlightenment on maternal health services utilization and male responsibilities should be effectively carried out in all communities especially among the Nupe and Hausa whose wives hardly utilize the ANC services. Women empowerment programmes should be put in place to improve the women‟s economic power, maternal health services should be made free as earlier proclaimed by the government. There should be effective community participation in facility management and other health care activities to encourage service utilization.
1.1 Background to the Study
Reduction in maternal mortality and morbidity has been the focus of several international conferences and programmes. From the introduction of primary health care in 1978 through the Bamako Initiative, Safe Motherhood and the Millennium Development Goals, most programmes were aimed at improving quality, access and utilization of health services by all the people with special attention given to women and children (Hiluf and Fantahun, 2008). Instead of improving access, quality and utilization of health services, the introduction of various health policies and programmes in many developing countries resulted in inequalities in terms of coverage of citizens and quality of services available to the people (Ha, Berman and Larson, 2002).
Maternal health care service encompasses family planning, preconception, antenatal, delivery and postnatal care. Goals of preconception care include providing education, health promotion, screening tests for various health problems and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Women who begin prenatal care early in their pregnancies have better birth outcomes than those who receive little or no care during their pregnancies. Postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, and family planning (Mwaniki, Kabiru and Mbugua, 2002).
Maternal health care services (MCH) are essentially promotive and preventive and provide avenues for the early detection of mothers at high risk of illness and mortality during pregnancy, labour and postnatal periods (Al-Nahedh, 1995; Lucas and Gilles, 2003; Olugbenga-Bello, Asekun-Olarinmoye, Adewole, Adeomi and Olarewaju, 2013). As the majority of patients
utilizing the MCH services are usually not ill, and pregnancy is most frequently an uneventful physiological process, it is logical to hypothesize that, given the slightest constraints, maternal health services would be underused. The objective of maternal health care is to ensure that expectant and nursing mothers have normal delivery, and bear healthy children and maintain good health. This process starts at the time of conception of the child (Rogan and Olvena, 2004). While antenatal care ensures that the health of expectant mothers, especially their nutritional status is safe guarded and avoidable complications of pregnancy are prevented, the natal care also includes the care for expectant mothers during childbirth, preferably by a nurse, midwife or a doctor. The postnatal care covers maternal health care services after delivery including health monitoring of the newborn baby while family planning ensures full recovery of the woman from previous childbirth and improves the child‟s chance of survival (Digambar and Sahoo, 2011).
Thus, the United Nations Fund for Population Activities (UNFPA, 2006) stated that the main objectives of the maternal health care services are the provision of antenatal care, skilled assistance for normal deliveries, appropriate referral for women with obstetric complications and postnatal care. Other objectives are provision of family planning and other reproductive health services such as infertility care services and emergency obstetric care including provision for caesarian section and emergency blood transfusion. These services are to be provided in the community within the scope of the primary health care services by skilled health personnel.
It has been reported that maternal health reflects the level of social justice and the degree of respect for women‟s rights in a given society (United Nations, 2001). Women‟s right to receive quality health services is guaranteed when their basic human rights to education, good nutrition, safe environment, access to economic resources and to participation in decision-making are met (WHO/UNICEF/UNFPA, 1999; USAID, 2013). Although, the Primary Health Care (PHC) adopted by the WHO in 1978 as the best strategy for the provision of health care services includes maternal and child health as one of its components, it was at the Nairobi Safe Motherhood Conference in 1987 that the magnitude of problems women go through as a result of pregnancy and childbirth were brought to the fore (Starrs, 1997). The Safe Motherhood Initiative that resulted from the Nairobi conference articulated strategies for the promotion of safe motherhood in consonance with the principles of primary health care. These principles include equitable distribution of health care services, prevention rather than cure and community participation in health care services. The WHO (1987) stated that promotion of maternal and child health is also the emphasis of the Bamako Initiative that was articulated by the African Ministers of Health in 1987 as a strategy for ensuring access to essential drugs.
Despite the introduction of the various measures to curb maternal mortality and morbidity, the use of maternal health services was found to be disproportionate among the people. In a study, Swenson, Thang, Nhan and Tieu (1993) and Toan, Hoa, Thach, Hoer and Perrsson (1996) reported that socio-demographic characteristics such as education, occupation, traditional beliefs and number of children are related to the use of antenatal care in Vietnam. The Federal Ministry of Health (2008) reported that the health behaviour of Nigerian women regarding pregnancy-related care remains poor and poses one of the greatest challenges to maternal mortality reduction in the country where less than two-thirds of pregnant women received antenatal care in 2005.
It has been reported that the utilization of maternal health care services is lower in Nigeria especially in the Northwest and parts of the north-central regions like Nasarawa and Niger states (Azuogu, Azuogu and Nwonwu, 2011). While the social, political and economic context of the health care system influences access to maternal health care, and therefore affects maternal mortality and morbidity, maternal health-seeking behaviour also plays a key role in the utilization of maternal health services in parts of Niger State (Garba, Hellandendu, Ajayi, Suleyman and Oluwabamide, 2011). Common problems that contribute to the low utilisation of health services include the lack of compliance of services with defined standards, the shortage of supplies, infrastructural problems like poor roads and lack of facilities, deficiency in detection and management of complications or emergency cases, and poor client-provider interaction. WHO/UNICEF/UNFPA (2001) added that maternal health services are also underutilized when they are perceived to violate women’s rights and needs, or are not adapted to the cultural contexts of the people. Therefore, the provision of good-quality care is one of the most effective ways of ensuring that maternal health services are used, and that women’s lives are saved. This can be achieved by ensuring high standards of care, decreasing barriers to care, ensuring the empowerment and satisfaction of users and motivation of providers by involving them in decision-making. Thus, improving provider responsiveness to cultural and social norms is an important tool towards ensuring the provision of good quality and women friendly services and as well ensures effective utilization for maternal health services. This “women-friendly” approach focuses on the rights of women to have access to quality care for themselves as individuals and as mothers, and for their infants. It is part of a broader strategy to reduce maternal and neonatal morbidity and mortality and requires strong partnerships between governments, health systems and communities. These burdens of maternal mortality and morbidity have been variously reported to be influenced by ignorance, access to care, quality of care, poverty, cultural and religious factors among other things. The study is thus, set to investigate how these factors influences the utilization of maternal health services in primary health care facilities in Niger State.
1.2 Statement of the Problem
Vast discrepancies continue to exist in access to and utilization of maternal health services in both the developed and the developing countries. These discrepancies are said to occur between the rich and poor women, between the young and the old women, between the urban and rural women and between the literate and non-literate women. While many of the barriers to the use of maternal health services such as educational status of women, low economic status and religion are not directly linked with access and quality of maternal health services, there are many barriers that maternal health systems interventions could address. These include financial and geographic access, perceived and actual quality of care as well as the knowledge and attitudes of the people on the importance of maternal health services (Freedman et al, 2005). Most of these barriers are responsible for the differences in the utilization of maternal health services among women in many parts of the world. Despite the fact that maternal health care utilization is essential for further improvement of maternal and child health, little is known about the current magnitude of use and factors influencing the use of maternal health services as provided within the scope of primary health care in rural areas of most parts of Nigeria.
Nigeria, the most populous country in Africa, has one of the highest maternal mortality rates in the world and like in most countries in the developing world, maternal mortality rate in Nigeria is on the increase (Ujah, Aisien, Mutihir, Vanderjag, Glew and Uguru, 2005). In most areas of sub-Saharan Africa, restructuring of public health facilities such fragmentation of health care services, specialization of health care services and increasing concentration of health resources in the urban areas have promoted dangerous inequality, social upset and disintegration of all forms of infrastructure that were built in the 1960‟s and 1970‟s including those of the health care services. It has been observed that poverty and ignorance are on the increase in most parts of the sub-Saharan Africa with Nigeria grossly affected. The cumulative effect is seen on education and maternal and child health. It has been argued by Harrison (1997) that maternal mortality ratio of a country reflects not only the adequacy of obstetric care but also the general level of social and economic development. Although a large number of publications have been made on maternal mortality in Nigeria, there are only few of these that report on the situation in north-central region of the country where Niger State is located. The region is peculiar because it is inhabited largely by the ethnic minorities of the Middle Belt of Nigeria with their distinct cultures and customs.
Maternal mortality is one of the major health challenges currently confronting Nigeria. As a result of its recognition by the member states of the United Nations as one of the priority development challenges that need to be urgently addressed, the global community has endorsed the reduction of maternal mortality as one of the eight Millennium Development Goals (United Nations, 2000). Estimates have shown that more than 99% of global maternal deaths occurred in the developing countries. Nigeria with an estimated 150, 000 -165,000 annual maternal deaths is ranked 2nd as the country with the highest number of maternal deaths in the world. Most of these deaths are said to be occurring in the rural areas where two-thirds of the country‟s population lives require in-depth studies and quick interventions (WHO, 2006). According to the 1999 Multiple Indicators Cluster Survey, the maternal mortality ratio in rural areas is more than 828 maternal deaths per 100,000 live births which is more than double that of the urban areas of 351 maternal deaths per 100,000 live births. With an estimated national maternal mortality ratio of 704-1,000 per 100,000 live births, and with about 2.4 million live births annually, some 170,000
Nigerian women die as a result of complications associated with pregnancy and child birth (Federal Office of Statistics/UNICEF, 2000; UNFPA, 2001).
The Niger State Millennium Development Goals (MDGs) Committee (2006) reported that as against the national target of less than 75 per 100,000 live births, Niger State had a maternal mortality ratio of 800 per 100,000 live births in 2003. This is said to have reduced to 548,000 per 100,000 in 2010 (Niger State Ministry of Health, 2012). In addition, percentage of births attended to by trained health personnel was low at 45 % as at 2003. This was reported to have improved to 61% in 2010 (Niger State Ministry of Health, 2012). During the same period, only one fifth of women who delivered went for postnatal care. The National Demographic and Health Survey (NDHS, 2008) reported an annual population growth rate of 3.4% and a total fertility rate of 5.9 for the state as against the national annual population growth rate of 3.2% and fertility rate of 5.7. The report added that poor condition of the health facilities and health services which are being provided by the primary health care in the state and the low patronage of health care system accounted for the high maternal mortality rate. In fact, only 8.1 % of the people were reported to have patronized health facilities in the State in general.
It has been observed that multiple factors underlie women‟s capacity to survive pregnancy and childbirth. These factors include women‟s health and nutritional status, their access to and use of health services, household practices and people‟s behaviours with regard to women‟s health in the society. All these are linked to the low status of girls and women in the society.
The situation is worse in Nigeria due to inadequate access to modern health services and poor utilization. For, despite the government’s commitment to deliver health facilities at the doorsteps of common people through innovative approaches, such as the introduction of Primary Health Care, the utilization of health services in some parts of Nigeria is still far below acceptable standard (FMOH, 2005). One of the public health challenges in Nigeria is how to access vulnerable groups with the needed preventive and curative health services. Most Nigerian women resident in the rural areas especially in the northern part of the country where literacy level among women is low do not have access to reproductive health education that they need (Ejembi et al, 2006). Thus, in many developing countries, complications of pregnancy and childbirth mostly at the level of preconception and prenatal care are the leading causes of death among women of reproductive age (Ramachandran, 1989). Therefore, reducing maternal mortality requires coordinated, long-term efforts at the household and community levels as well as at the level of national legislation and policy formation especially in the health sector.
Despite the introduction of the various measures to curb maternal mortality and morbidity, the use of maternal health services is found to be disproportionate among the people. In a study, Swenson, Thang, Nhan and Tieu (1993) and Toan, Hoa, Thach, Hoer and Perrsson (1996) reported that socio-demographic characteristics such as education, occupation, traditional beliefs and number of children are related to the use of antenatal care in Vietnam. The Federal Ministry of Health (2008) reported that the health behaviour of Nigerian women regarding pregnancy-related care remains poor and poses one of the greatest challenges to maternal mortality reduction in the country where less than two-thirds of pregnant women received antenatal care in 2005.
It has been reported that the utilization of maternal health care services is lower in Nigeria especially in the Northwest and parts of the north-central regions like Nasarawa and Niger states (Azuogu, Azuogu and Nwonwu, 2011). While the social, political and economic context of the health care system influences access to maternal health care, and therefore affects maternal mortality and morbidity, maternal health-seeking behaviour also plays a key role in the utilization of maternal health services in parts of Niger State (Garba, Hellandendu, Ajayi, Suleyman and Oluwabamide, 2011). Common problems that contribute to the low utilisation of health services include the lack of compliance of services with defined standards, the shortage of supplies, infrastructure problems, deficiency in detection and management of complications or emergency cases, and poor client-provider interaction. WHO/UNICEF/UNFPA (2001) reported that maternal health services are also underutilised when they are perceived to be disrespectful of women’s rights and needs, or are not adapted to the cultural contexts. Therefore, the provision of good-quality care is one of the most effective ways of ensuring that maternal health services are used, and that women’s lives are saved. This can be achieved by ensuring high standards of care, decreasing barriers to care, ensuring the empowerment and satisfaction of users and motivation of providers by involving them in decision-making.
According to the Niger State Ministry of Health (2013), reports from some health personnel providing maternal health services in some health facilities across the state indicated poor attendance at antennal clinics and high rates of child deliveries at home. Some of the children delivered at home were eventually presented in the hospitals and clinics with complications either affecting the mothers or the children or both at various times while the few that delivered their babies in the hospitals/clinics usually arrived the health facilities late and in distress. The information added that many maternal deaths occurred at homes in various communities across the state. Few of the deaths occurred in the hospitals and clinics mainly made up of mothers who arrived the clinics when it was too late to remedy their conditions. Most of these deaths and complications were occurring as result of the fettered access to the maternal health services provided by the primary health care as a result of several socio-cultural factors such as ignorance, traditional practices and poor transportation system in many rural areas of the state while poverty and poor quality of the services are said to be important factors contributing to the poor utilization of the services.
Current health reform efforts in Nigeria have reiterated the centrality of Primary Health Care in health development. However, given the slow pace of progress of PHC implementation in the country, the goal of attainment of health for all Nigerians using the PHC approach appear to be a mirage. There is therefore, an urgent need to assess and review the strategies and methodologies of PHC implementation in the country with a view to improving the services and investing in systems development and building the capacities of communities and LGA to plan and implement PHC programmes.
Despite the availability of few records concerning utilization of maternal health services in Niger State, no documented research evidence is available to show the pattern and level of utilization of the services among women in the rural areas across the state. In addition, no documented cross-sectional study has been conducted to identify the levels of utilization of various components of the services by women in the rural areas. This study is therefore, aimed at assessing the quality of modern maternal health services provided at the primary health care level, the women‟s access to and utilization of modern maternal health services and to identify the factors that serve as barriers to quality, access and utilization of modern maternal health services among women in Niger State, Nigeria.
From the above statement of the research problem, the following research questions are raised:
- What is the current state of maternal health services in primary health care facilities in Niger state?
- Do the women have access to maternal health services in the primary health care facilities in the State?
- What are the common maternal health problems affecting women in Niger State?
- What is the level of utilization of modern maternal health services at the primary health care facilities in Niger State?
- What are the socio-cultural factors associated with utilization of modern maternal health services in Niger State?
1.3 Objectives of the Study
The main aim of the study is to assess the quality of modern maternal health services provided at the primary health care level and to determine women‟s access to and utilization of modern maternal health services in the PHC facilities. In addition, the study is aimed at identifying the factors that serve as barriers to quality, access and utilization of modern maternal health services among women in Niger State, Nigeria. The specific objectives of this study are:
- To evaluate the current state of modern maternal health services in primary health care facilities in Niger State.
- To determine whether women of childbearing age have access to maternal health services in Niger State.
- To identify the common maternal health problems in Niger State.
- To determine the level of utilization of maternal health services in Niger State.
- To identify the socio-cultural factors influencing the utilization of various modern maternal health services by women of childbearing age in Niger State.
1.4 Significance of the Study
The poor state of maternal health in many parts of northern Nigeria especially in Niger state is partly due to inadequate modern health services and poor utilization of the available ones by women of childbearing age. Despite the Niger State‟s government‟s commitment to deliver health services at the doorsteps of common people through innovative approaches such as the Primary Health Care (PHC), the availability and utilization of health services is still far below any acceptable standard in many parts of Niger State. This problem is more visible in the rural areas where literacy rate is low, poverty and cultural practices are high and access to health care services is low. It is therefore, necessary to identify the vulnerable groups and the factors responsible for their vulnerability. This is necessary especially in Niger State where most of the basic social amenities such as road network, clinics, water supply and schools are inadequate since an important proximate determinant of maternal mortality is access to and use of quality health care services.
Since access to quality reproductive health services is crucial for improved maternal health and child survival, the identification of individual and group factors that may facilitate or impede the effective use of health care services for preventing and treating maternal morbidity may help the government, health personnel and people of Niger State to identify the women who may be particularly vulnerable to maternal mortality and morbidity, and provide information that policy makers can use to target services to those in greatest need. This will in turn help in reducing maternal mortality and morbidity and improve child survival in the State. Findings from this study could therefore serve as bases for improved maternal and child health services within the context of primary health care services and subsequent reduction in maternal morbidity and mortality.
Findings of this study will improve the scope for sociological studies especially in the areas of health behaviours, community participation in health care programmes, women empowerment programmes across ethnic groups and effective utilization of health services among the rural people. It would also serve as bases for sociological studies of effects of cultural sanctions on men that neglect the health care of their wives. Findings will provide bases for public enlightenment on the need for male support to females in reproduction and child rearing.
1.5 Scope and Delimitation of the Study
The study was conducted in the three senatorial districts of Niger State, Nigeria. It investigated availability, access, quality and patterns of utilization of maternal health services in the primary health care centres in Niger State. The study specifically identified the quality of maternal health services provided at the primary health care level and the socio-cultural factors that influenced their utilization among women of childbearing age in Niger State.
The study investigated patterns of utilization of existing maternal health services across age, level of educational attainment, ethnic and religious divides of the women in Niger state. It was conducted in Niger State because of the State‟s ethnic, cultural, religious and economic plurality. The State is poor in terms of social amenities like schools, hospitals, road network and water supply. In addition, the state is among those with poor maternal health indicators especially in the North-central geopolitical zone of Nigeria.
1.6 Definition of Terms
This is the health care women receive throughout the period of pregnancy in order to ensure that the women and their newborns survive pregnancy and childbirth (Fraser, 2006).
This refers to bleeding from or into the genital tract occurring from 24th weeks of pregnancy and prior to the birth of the baby (Royal College of Obstetricians and Gynaecologists, 2008).
Is the onset of seizures (convulsions) before, during or after childbirth in a woman with high blood pressure and large amount of protein in urine during pregnancy (Richards, Graham and Bullock, 1989).
Emergency Obstetrics Care
It is a set of health interventions called signal functions that should be available in a health care facility that provides immediate care for women with pregnancy-related complications (UNFPA, 2011).
Intranatal care refers to health care services provided to a woman while in labour (Fraser, 2006).
Maternal Health Services
These are comprehensive health services concerned with the entire maternity cycle i.e. care given to a woman during antenatal, intranatal, postnatal and the inter-conceptional periods (Assfaw,2010).
It is the dealth of a woman while pregnant or within 42 days after termination of pregnancy, irrespective of the durationand site of pregnancy, from any cause related to or aggravated by the pregnancy or its management (WHO, 1993).
This refers to physical and psychological conditions that results from or are aggravated by pregnancy and have an adverse effect on a woman‟s health (CDC, 2014). Millenium Development Goals (MDGs)- These are a set of eight time-bound development objectives that seeks to address issues of poverty, education, gender equality, health, environment and global partnerships for development agreed by international community to be achieved by the year 2015 (UN, 2007).
Health care given to the mother and the newborn baby immediately after childbirth through the first 42 days after childbirth (Park, 2006).
According to Weeks (2008) is the loss of more than 500mls of blood within the first 24 hours following childbirth.
Primary Health Care (PHC)
It is an essential care based on practical, scientifically sound and socially acceptable methods ans technology made universally accessible to individual, families and community, through their full participation and at a cost that the country and community can afford to maintain at a every stage of their development in the spirit of self reliance and determination (WHO, 1978).
It is the time from the delivery of the placenta through the first few weeks after delivery usually within six weeks (Fraser, 2006).
Quality Maternal Health Services
According to USAID (2007), this refers to maternal health services provided with specific considerations given to physical environmental of the health facility, technical competence of the personnel, facility management and continuity of care.
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