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ABSTRACT

The purpose of the study was to determine the Provision, Utilization, and Enhancement Strategies of Maternal Health Services in Enugu State. Fourteen specific objectives and corresponding research questions were posed to guide the study while five hypotheses were postulated and tested at .05 level of significance. The population for the study consisted of one hundred and seventy nine thousand and six (179,006) respondents. The sample for the study consisted of two thousand nine hundred and fifty nine (2,959). Four instruments were used for data collection: two questionnaires one for staff and one for pregnant women, MHS Key Informant Interview Schedule (MHSKIIS), and MHS Focus Group Discussion Guilde (MHSFGDG). Questionnaire on MHS Provision (QMHSP) and MHS Utilization Questionnaire (MHSUQ). QMHSP elicited quantitative information on provision of MHS while MHSUQ elicited quantitative information on utilization of MHS and enhancement strategies from the women of child bearing age. The MHSKIIS and MHSFGDG elicited qualitative information on provision, utilization and enhancement strategies. The Crombach Alpha Statistics and Kudder-Richardson formula were used for testing the reliability. The reliability index were section B= .93, .97,

.78 and .94; for MHSUQ were section B= .62, .64, and .89. Results of the study showed that: antenatal care services (=2.85) and post-natal services (=2.99) were moderately provided while delivery care services (=3.68) were provided to a high extent. Drugs and equipment (=2.60) were moderately provided. ACS services were utilized to a high extent (=3.63). Delivery care services were utilized to a moderate extent. Postnatal care services were utilized to a high proportion. All the women agreed that all the listed strategies were capable of enhancing MHS. Women of child bearing age, aged 15-34 years and 35-49 years utilized ACS services to a high extent. ACS services in urban (=3.66) and rural (=3.58) locations were utilized of women of child bearing age to a high extent. There were significant differences in the utilization of MHS by women of child bearing age according to location, age, parity, location and level of education. Recommendations among others were that the Ministry of Health should increase the supply of MHS drugs and equipments in both urban and rural locations, and provide more basic amenities like toilets, lighting, delivery mats, detergents and water in these centers.

 

 

 

CHAPTER ONE

Introduction

Background to the Study

Maternal health services (MHS) are major health concern globally. This is because they support and determine the state of maternal health of any country. Maternal health is essential for the survival of human race in both developed and developing nations, including Nigeria. Global leaders reemphasized the reduction of maternal mortality as the fifth target of millennium development goals – MDGs (Lucas and Gill es, 2003). About 99 per cent of all maternal deaths occur in developing countries, while less than one per cent of maternal deaths worldwide occur in developed countries (Bayer, 2001). This indicates that maternal deaths could be avoided if the proper health resources and services were available to women in developing nations. Most of these conditions like obstructed labour could be prevented with proper provision and utilization of maternal health services.

MHS are those services provided to women of child bearing period (15-49 years) for prevention, early detection and treatment of health hazards or diseases that may affect the normal child bearing (Mahaba, 1996). MHS are essential obstetrics care with effective communication and transportation between the community-based services and the referral centre (Lucas & Gilles, 2003). They are also services planned for pregnant women and rendered to make them to be in good health during pregnancy, deliver safely, and maintain good health up to 6 weeks following delivery. To the best of my knowledge and accessibility no study was done on provision and utilization of maternal health services in Enugu state. In this study, MHS shall be regarded as organised services which are provided to cater for the health needs of women of child bearing age during pregnancy, delivery and post-natal periods. The objectives of MHS are to ensure that as far as possible pregnant women should remain healthy throughout pregnancy, deliver healthy babies and recover fully from the physiological changes that take place during pregnancy and delivery. These services include antenatal care services, delivery care services, and postnatal care services.

Antenatal care services are regarded as pregnancy related health care checkups, which could occur either in a health facility or at home. With improved understanding of the need for women to prepare physically, mentally and even logistically for childbirth, antenatal care is recognized as a key maternal health service in improving a wide range of health outcomes for women and children (Carroli, Rooney, & Villar, 2001; Chen, Wen, Yang & Walker, 2007). Antenatal care services represent the opportunity to deliver interventions for improving maternal nutrition, providing health education, encouraging skilled attendance at birth and use of facilities for Emergency Obstetric Care (EMOC). Having a sufficient number of antenatal care visits and receiving appropriate and timely care during the visits ensure that women prepare for the childbirth.

World Health Organization – WHO (2001) recommended a minimum of four antenatal care visits, based on reviewing the effectiveness of different models of service delivery. They also specified the content of antenatal care visits, which include blood pressure measurement, urine testing for bacteriuria and proteinuria, and blood testing to detect syphilis and severe anemia. Some other services, including giving tetanus immunization, providing iron and folate tablets and teaching women about danger signs of pregnancy complications. The contents of antenatal care provide an indication of its quality. Pregnancy complications are primary sources of maternal and child morbidity and mortality, and therefore teaching women about signs associated with pregnancy complications and the appropriate action to take, are important components of antenatal care service.

Delivery care services are the assistance and medicare given at delivery which reduces the health risks of mother and children (National statistical office Malawi and Opinion Research Company Macro International-ORC, 2005). Delivery care services involve monitoring the women, relief of pain during delivery, conservation of energy and prevention of exhaustion, injury and excessive blood loss. The midwife requires significant knowledge and experience to enable her recognise and detect deviation from normal course and care for the women adequately. Delivery care services through access to health facilities and skilled health personnel are two important interventions for safe motherhood. This ushers the women to postnatal care.

Postnatal care services encompasses checkups with a health professional within six weeks of childbirth. It requires physical care for example general examination from head to toe, examination of lochia and perineal suture lines, psychological care which include enough rest and normal behavior with others establishing satisfactory mother-child relationship, social care in terms of allowing her to interact with people, and educational care teaching the new mother the basic things about good maternal nutrition how to ensure successful breast feeding, family planning and promotion of hygiene to prevent infection. It involves rooming in, that is, the baby in his cot remains at the mother’s bedside for 24 hours, mother and baby being treated as a unit. It is important for mothers to receive care at this time as it has been recorded that more than 60 percent of maternal deaths take place during the postnatal period (Gill, Pande & Malhotra, 2007). Adequate provision and utilization of these services ensure safe motherhood.

Provision is defined according to Merriam-Webster (2014) as the act or process of supplying or providing something. In the context of this study, provision was regarded as supplies of necessary things ready for use to achieve better maternal health. Services to be made provision for include antenatal care services(e.g., blood pressure measurement, urine testing, blood testing, tetanus immunization, provision of iron and folate tablets, and teaching women about danger sign of pregnancy complication), delivery care service (skilled health personnel and access to health facilities) and postnatal care services (e.g., family planning services, techniques to avoid unwanted pregnancies can be given, maternal and child nutrition, immunization, hygiene and sanitation, prevention of infections including HIV and other STIs). Provision and utilization of these services are important for a successful outcome of pregnancies.

Utilization, on the other hand is the use of something in an effective way (Macmillan, 2007). In the context of this study, utilization shall be seen as use of maternal health services in an effective way. The utilization of maternal health services is one of the important factors to reduce the incidence of maternal mortality.

Maternal health services provision and utilization are supplies of necessary things ready for use to achieve better maternal health and use of those things in an effective way in order to reduce the incidence of maternal mortality. It is pertinent that mothers are aware of the enhancement strategies so that they see utilization as necessary.

Enhancement means to improve something either in quality, amount or strength while strategies mean planned series of action for achieving something (Longman, 2007). In the context of this study enhancement strategies mean planned series of action for improving maternal health services. Such strategies include: giving formal education to the women and empowering them economically, improving provision of health education to women especially on danger signs during pregnancy and delivery, creating awareness in communities to motivate pregnant women to attend antenatal clinic as this will in turn encourage them to seek post natal care, training of health personnel and providing more health facilities among others. In other to succeed with the improvement of maternal health services, there are some demographic factors which may have some positive or negative influence on maternal health services.

Socio-demographic factors have been found to influence the health services provision and utilization for mothers (Stephenson and Tsui, 2002). Some of these socio-demographic factors include: maternal age, parity, location and maternal education. These four variables were considered in this study. Maternal age is an important demographic factor which may influence the use of MHS (Bhatia & Cleland, 1995 & Mitra Al-Sabir, Cross & Jamil, 1997). Women under 18 or over 34 years of age are considered at greater obstetric risk (Amini, Catalano, Dierker & Mann, 1996). Sari (2009) revealed that women between 20 and 34 years

utilized MHS more than women between 35 and 49 years. The low level of utilization recorded among older women maybe due to increased experience in pregnancy and childbearing leading to the belief that they no longer need the assistance of a professional, especially if they had no complication (Adamu, 2011).

Parity refers to the number of pregnancies a women has had. More children are usually associated with increased physical and material responsibilities which leave them with little time and financial resources to care for themselves and discourage them from utilizing MHS than those with few children (Kamal, 2009). Celik and Hotchkiss (2000) noted that women who are delivering their first child were found to be significantly more likely to use prenatal care and trained assistance during delivery than women in the higher parity. Moreover, having a larger number of children may cause resource constraint, which has been found to be negatively associated with maternal health services-MHS use (Wong, Popkin, Guilkey & Akin, 1987; Chakraborty, Islam, Chowdhury, Bari & Akhter, 2003).

Location has been found to influence the utilization of MHS. Nwogu (2009) found that higher percentage of women utilized MHS in urban than those in rural locations. Gwatkin, Rustein, Johnson, Pande and Wagstaff (2000) noted that in many African countries where there may be difficulties with transportation women from rural areas have to walk long distances to reach the nearest health services while in the urban, transportation was easier. In rural areas roads may be rough or even impossible to use at certain times of the year, while in the urban, transport is easier (Orji, Ogunloa & Onwudiegwu, 2002).

Maternal education is considered one of the strongest factors associated with maternal health services use (Basu, 1990; Mitra, Al-sabir, Cross & Jamil, 1997; Prince, 1999). Some other studies also show that the determinant of health services use found most consistently is a woman’s educational attainment (Nuwaha & Amooti-kaguna, 1999; Maggadi, Madise & Rodrigues, 2000). Kawahara (2010) observed that the higher a women’s level of education the more likely she is to utilize MHS. Rogan and Olvena (2004) found maternal schooling strongly and positively associated with utilization of MHS. In this study, influence of maternal education in Enugu state will be determined.

Enugu state has seventeen local government areas (LGAs) with three senatorial zones. It has both urban and rural settings. Some of the socio-cultural and religious practices negatively influence some health programmes. Some women have little or no knowledge of basic health information. These predispose the pregnant women to some of the maternal health services problems under study. The state is divided into seven health districts; each health district is made up of between one to three LGAs. The public sector health facilities comprises two tertiary hospitals, six district hospitals, two sub district hospitals, 56 cottage hospitals, 189 health centres, 39 health clinics, and 131 health posts that carry out maternal health services. There are also 631 private health facilities, out of which 567 health facilities offer maternal health services. Both the government and private owned health facilities were considered in the study to ascertain a true picture of the extent of maternal health service provisions and utilization in the state, and also allow for comparison.

Statement of the Problem

Maternal health services are supposed to be provided adequately and are expected to be well utilized by women of child bearing age to ensure safe motherhood. The MHS are antenatal care services, delivery care services and postnatal care services. They include; provision for checking blood measurement, urine testing, blood testing, tetanus immunization, iron and floated tablets and teaching the women about danger signs of pregnancy complications. Also, provision for skilled attendants for delivery care, equipment, drugs and supplies necessary for effective prevention and management of obstetric complications should be made (WHO, 1999). Utilization of these services provided could save unnecessary severe complications and deaths among women during pregnancy, delivery and after delivery (Sari, 2009). Sari noted that numerous factors such as characteristics of healthcare system, including accessibility, acceptability, cost and quality of care have contributed directly with the use of maternal health services.

Available data indicate that maternal mortality ratio is high in Enugu state with figures ranging from 772 to 998 per 100,000 (Onah, Okoro, Umeh & Chigbu, 2005). Unfortunately, increased cases of maternal and child mortality raise serious concern over the level of provision and utilization of MHS, such services are expected to reduce incidence of high mortality among mothers and children. The implication of this, is that increased cases of maternal and child death are reflection of the level of provision and utilization of MHS.

Following from the above, one is therefore compelled to ask whether MHS are adequately provided in Enugu state; whether the provided services are maximally utilized; and if they are not, what strategies can be used to enhance their utilization. These, in the main, constitute the problem of the study.

Purpose of the Study

The purpose of this study is to determine the maternal health services provision, utilization, and enhancement strategies in Enugu state. Specifically, the study was carried out to find out the:

1. extent of antenatal care services provision in Enugu State;

2. extent of delivery care services provision in Enugu State;

3. extent of postnatal care services provision in Enugu State;

4. extent of MHS drugs and equipments provision in Enugu State;

5. extent of antenatal care services utilization by women of child-bearing age in Enugu state;

6. extent of delivery care services utilization by women of child-bearing age in Enugu state;

7. extent of postnatal care services utilization by women of child-bearing age in Enugu state;

8. extent of MHS provision in Enugu state based on urban-rural locations;

9. extent of MHS provision in Enugu state based on types of health facilities;

10. extent of MHS utilization by women of child-bearing age in Enugu state based on age;

11. extent of MHS utilization by women of child-bearing age in Enugu state based on parity;

12. extent of MHS utilization by women of child-bearing age in Enugu state based on locations;

13. extent of MHS utilization by women of child-bearing age in Enugu state based on level of education; and

14. MHS enhancement strategies among women of child-bearing age in Enugu state.

Research Questions

The following research questions were formulated to guide this study.

1. What is the extent of antenatal care services provision in Enugu State?

2. What is the extent of delivery care services provision in Enugu State?

3. What is the extent of postnatal care services provision in Enugu State?

4. What is the extent of MHS drugs and equipments provision in Enugu State?

5. What is the extent of antenatal care services utilization by women of child-bearing age in Enugu state?

6. What is the extent of delivery care services utilization by women of child-bearing age in Enugu state?

7. What is the extent of postnatal care services utilization by women of child-bearing age in Enugu state?

8. What is the extent of MHS provision in Enugu state based on urban-rural locations?

9. What is the extent of MHS provision in Enugu state based on types of health facilities?

10. What is the extent of MHS utilization by women of child-bearing in Enugu state based on age?

11. What is the extent of MHS utilization by women of child-bearing age in Enugu state based on parity?

12. What is the extent of MHS utilization by women of child-bearing age in Enugu state based on locations?

13. What is the extent of MHS utilization by women of child-bearing age in Enugu state based on level of education? and

14. What are the MHS enhancement strategies among women of child-bearing age in Enugu state?