Utilization Of Antenatal And Maternity Services By Mothers Seeking Child Welfare Services In Nigeria
This study aims to analyze the determinants of utilization of antenatal and maternal health care services among mothers seeking child welfare services with focus on the continuum of care for pregnant women during pregnancy and delivery, that is, the use of antenatal care services and skilled assistance during delivery. This study used data from 2008-09 N-DHS for women with a last birth in the five years preceding the survey. Descriptive methods of analysis and multivariate ordinal regression method of analysis were used to determine the significance of independent variables on the utilization of antenatal care and delivery services. Independent variables for this study include: age, marital status, level of education, type of place of residence and household wealth index. 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.
1.1 Background of the Study
Maternal and child health has emerged as the most important issue that determined global and national wellbeing. This is because every individual, family and community is at some point intimately involved in pregnancy and the success of childbirth (WHO, 2006). Despite the honour bestowed on womanhood and the appreciation of the birth of a new born baby, pregnancy and childbirth is still considered a perilous journey. The situation of maternal and child health in Nigeria is among the worst in Africa and has not improved substantially and in some areas of the country, has worsened over the past decade (Ladipo, 2009). The maternal mortality ratio ranges between 800-15000 per 100,000 live births (Nigeria Demographic and Health Survey, 2003), with marked variation between geo-political zones – 165 in South West compared with 1,549 in the North-East and between urban and rural areas (Ladipo,2009). Total fertility rate is 5.7 births per woman and it is estimated that approximately 59,000 of maternal deaths take place annually in Nigeria as a result of pregnancy, delivery and post-delivery complications (WHO, UNICEF, UNFPA, 2007).
Research (Ladipo, 2009) indicated close link between the health of the new born with the health of their mothers. About 30-40% of neonatal and infant deaths result from poor maternal health and inadequate care during pregnancy, delivery and the critical immediate postpartum period (Ladipo, 2009). In Nigeria 340,000 infants die every year during delivery and shortly afterwards especially if the mother dies in childbirth (WHO, UNICEF, UNFPA, 2007). The under-five mortality ratio is 200 per 1000 live births (WHO, 2006). These deaths are not unconnected with the poor maternal health services in the country and could be avoided through provision of quality and effective maternal and child health services.
Nigeria is one of the African countries with a rapidly growing population. As a nation with a growing economy, one of the major health challenges facing the country today is the capacity to sustain the increasing infant and maternal health. The most common recorded cause of perinatal deaths are similar to those of other less developed countries, and the common denominators are early childbearing poor maternal health and above all, the lack of appropriate and quality services (Okereke, Kanu, Nwachukwu, Anyanwu, Ehiri & Merick, 2005). Although life-saving practices for most infants have been known for decades, currently one third of the mothers still have no access to health care services during pregnancy and almost half do not have access to health care services during childbirth (Okereke, et al., 2005). In the light of rapid population growth and increased risks of adverse environmental health exposures, maternal and child health prospects could be a serious national public health problem due to factors such as ignorance, apathy, poverty, lack of commitment, illiteracy and corruption (Opara & Ellah, 2007).
1.2 Problem Statement
The 2008-09 N-DHS 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 (KNBS 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 N-DHS 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 N-DHS maternal mortality rate of 488 deaths per 100,000 live births, this target is yet to be achieved.
Nigeria is characterized by low utilization of maternal health care services despite the various interventions. The community component of the KSPA 2010 report shows that women from rural part of the country 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 Nigeria, the use of skilled health professionals (the use of a doctor, nurse or midwife) during delivery aggregates to 25.8 percent (N-DHS 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 N-DHS shows that home deliveries increased from 70.6 to 73.3 percent, indicating low utilization of maternal health care services. Having highest proportions ofthose who gave birth on their own without assistance in both the 2003 and 2008 N-DHS 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 Research Question
- What factors influence utilization of maternal health care services in Nigeria?
1.4 Research objective
The aim of this study is to establish determinant factors in the utilization of antenatal and maternal health care services among women of reproductive age in Nigeria
1.4.1 Specific Objective
- To establish factors that determine the use of all maternal health care services
1.5 Justification of the study
Maternal mortality rates in Nigeria remain high and this study aims at contributing to better understanding about utilization of maternal health care services by expectant women in Nigeria. 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 N-DHS which interviewed 8444 women of age 15 to 49, 1039 from Nigeria 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.
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 states in the country.
Summary, Conclusions And Recommendations
This chapter presents a summary of the study findings and conclusions, as well as recommendations for programs and research drawn from the findings. Section 5.2 summarizes the study findings while section 5.3 gives recommendations based on the findings both to program implementers as well as recommendations for research.
The study set out to analyse the determinants of utilisation of maternal health services in Nigeria 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.
This study set out to determine factors that are associated with utilization of maternal healthcare services among women of reproductive age in Nigeria, Nigeria. 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.
Multivariate ordinal regression results indicate that type of place of residence, highest level being no education and middle wealth index are not significant in the model. Women with primary and higher education, young, married and rich are more likely to utilize maternal health care services.
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.
5.4.1 Recommendations for Programs
The findings show that utilization of maternal health services for Nigeria 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.
5.4.2 Recommendations for Research
More research is needed in understanding determinants of utilization of maternal health services specifically on why women of middle wealth are less likely to seek early antenatal visits and will not go for the 4+ visits compared to poor women. More studies also need to be done to understand why middle wealth is not a significant factor in utilization of maternal health services. Lastly, research should focus on why the rural women are utilizing maternal health care services more than women who reside in urban areas.
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