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utilization of antenatal care and delivery services among women of child bearing age in Udenu Local Government Area, Enugu State.


Project topic for Nursing Science department

 CHAPTER ONE

INTRODUCTION

  • Background of the study:

Prenatal care also known as antenatal care is a type of preventive health care which help to provide regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy and to promote healthy lifestyles that benefit both mother and child (Wikipedia).

Antenatal care (ANC) can also be defined as the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health during pregnancy (WHO, 2016).

The new international Webster’s comprehensive encyclopedia (2014) described women as adult human females or the females part of the human race. Therefore, women of child bearing age can be described as adult human female who are within the child bearing age or women within their reproductive age.

These women once they conceive are expectant mothers and are expected to report for ANC at different stages of gestation. Some present as soon as pregnancy is confirmed. Others much later in pregnancy and some are at the labour room for the first time. Those who present during labour are called the unbooked which shows under utilization or non-utilization of ANC services.

There are some factors which determines the utilization of antenatal care and delivery services such as educational level, age, socio-economic status, ethnic group, place of residence and the available type of health maintenance organization (Hava et al, 2006). Sometimes, the perceived behavior of health personnel which may includes claims of neglect, patient humiliation and rudeness at the hand of medical staff negatively affect ANC utilization and delivery services.

The term maternal health includes the women during pregnancy, child birth and post partum period. It encompasses the health care dimension of family planning, preconception, prenatal and postnatal care in order to reduce maternal morbidity and mortality (WHO 2012).

In developing countries like Nigeria, pregnancy and child birth complications are the major cause of maternal and child death and these deaths are attributed to the fact that majority of the pregnant women do not get the appropriate care they need as a result of certain barriers to the health care facilities.

In other wards, the reason for this review is to find out these factors that prevent women form having proper utilization of antenatal care and delivery services in Udenu Local Government Area.

The UN (MDGs) aims at improving maternal health. Maternal death and mortality according to World Health Organization (WHO) is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (WHO 2016).

Maternal mortality ratio (MMR) is the ratio of the number of maternal deaths during a given time period per 100, 000 lives births during the same time-period (maternal mortality dara.org2013).

The World maternal mortality rate had declined 44% since 1990 but still everyday 830 women die from pregnancy or childbirth related causes (maternal mortality ratio vs maternal mortality rate on pop. research institute website 2017).

According to the United Nations Population Fund (UNFPA) 2017 report, it is equivalent to “about one women every two minutes and for every women who dies, 20 or 30 encounter complications with serious or long lasting consequences. Most of these deaths and injuries are all preventive (UNFPA 2017).

Globally, high and middle income countries experience lower maternal deaths than low income countries (WHO et al 2012)

At a country level, India (19% or 56,000) while Nigeria (14% or 40,000) accounted for one third of the maternal deaths in 2010. (WHO Maternal mortality).

According to Manzur (2017), a further reduction of MMR is now part of the 2030 Agenda foe sustainable development. The UN has more recently developed a list of goals called the Sustainable Development Goals. The target of the third Sustainable Development Goals (SDG) is to reduce the global maternal mortality rate (MMR) to less than 70 per 100,00 live births by 2030. Some of the specific reasons for the (SDG) according to (“Health-UNSDGs) are to prevent unplanned pregnancies, as well as providing safe environment for delivery.

The WHO has also developed a global strategy and goal to stop preventable death related to maternal mortality and its major goals is to identify and address the caused of maternal mortalities and reproductive morbidities as well as disabilities related to maternal health outcomes.

  • It also aimed to ensure universal health coverage.
  • To implement strengthing health care systems to ensure quality data collection as well as responsibility and accountability to improve the quality of care provided to women.(“Maternal Mortality” – WHO).            

Recently, the WHO Technical working croup has recommended a minimum level of ANC to be four antenatal care clinic visits throughout the pregnancy (WHO 2016). The first visit which is expected to screen and treat anaemia, syphilis, screen for risk factors and medical conditions that can be best handled in early pregnancy and introduce prophylaxis if necessary (example for anaemia and malaria) is recommended to be held by the end of fourth month. The second, third and fourth visits are scheduled at 24-28 and 32-36 weeks respectively (UNFPA, 2004).

The aim of good prenatal care is to reduce maternal death rates ad miscarriages as well as birth defects. Low birth weights (LBW) and other preventable infant problems. These can be delivered through recommendation on adequate nutrition, exercise, vitamin intake and other nutritional foods and to direct the women to appropriate specialists                                           and hospital if necessary (Ojo, O.AQ & Briggs, E.B 2009). According to Diane, et al, 2003, antennal care consists of four components, which includes:

  • Monthly visit during the first two trimesters 1-28 weeks.
  • Biweekly visit from 28th week to 36th week of pregnancy.
  • Weekly after 36th week till delivery (28-40 weeks)
  • Assessment of parental needs and family dynamics.

Antenatal care is an important determinant of maternal health outcomes and one of the basic components if maternal care in which the life of mothers and babies depend. It is the entry point to the health care system and determines whether a mother will deliver in a healthy facility and whether she will take the baby for preventive services like immunizations and growths monitoring. According to Chuma and Thomas (2013), only a minority of pregnant women (36.1%) make the required minimum of four ANC visits in public health facilities in Kenya.

Lack of access to and low utilization of essential services and high impact interventions, together with poor quality of health services may be partially responsible for this lack of progress.

Improving maternal health is one of the (WHO) Millennium Development Goals (MDGs) and professional health care during child birth is one of the process indicators in assessing progress towards these goals.

WHO has also recommended four strategic interventions or four pillars for safe motherhood (WHO 1996). These includes the following:

The four strategic interventions includes:

  • Family planning
  • Antenatal care (ANC)
  • Clean/safe delivery and
  • Emergency obstetric care.

To provide opportunities for health education of both parents with respect to their own children’s well being.

To achieve the above objectives, women must be availed the antenatal service. The ANC service offered to mothers comprises:-

  • Physical examinations including the measurement of weights, assessment of gestational age by fundal heights and blood pressure recording.
  • Laboratory investigations including screening of anaemia (packed cell volume) retro-viral tests, urinalysis, blood grouping, genotype and various Sexually Transmitted Infections (STIs)
  • Ultrasonography for assessing the well being of the unborn child.
  • Prophylaxis and treatment for malaria and other presenting complaints/illness. Currently, the recommended intervention strategies for preventing malaria in pregnancy are intermittent preventive treatment (IPT) with sulfadoxine-pyrimethanime (SP) and insecticide treatment bed nets (ITNs). Decisions on the type of delivery care during labour will be taken during antenatal period.

Utilization of ANC services has been identified in a number of studies an important factor in determining maternal and infant mortality according to Holian J (1989). However, the use of health service is a complex behavioural phenomenon. It is related to the organization of the health delivery system and is affected by the availability, quality, cost, continuity and comprehensiveness of services. It is also effected by social structure, health beliefs, personal characteristics of the user as well as the accessibility of these services (Kroeger A. 1983).

1.1.1    Maternal Health in Nigeria

Nigeria has experienced some progress in the last two decades in reducing maternal deaths, but unfortunately, the number of women that die during pregnancy and childbirth due to complications arising from child delivery remains apparently high. Nigeria is the most populous and one of the wealthiest countries in Africa but with all these wealth, the country is still experiencing increase rates of maternal deaths.

Nigeria has the 10th highest Maternal Mortality Ratio in the world, according to UN estimates with 630 women dying per 100,000 birth, a higher proportion than in Afghanistan or Haiti, and only slightly lower than in Liberia or Sudan. (Ibid, p.23). an estimated 40,000 Nigerian mothers die in pregnancy or child birth each year and another 1 million to 1.6 million suffer from serious disabilities from pregnancy and birth related causes annually due to poor utilization of antenatal care and delivery services (WHO, UNICEF, UNFPA and WORLD BANK 2012).

Nigeria women have an average total of 5.7 births in their life with each pregnancy exposing them to the risk of maternal complication.

Over her life time, Nigerian women’s risk of dying from pregnancy or child birth is 1 in 29, compared to the sub Saharan average of 1 in 39 and the global average of 1 in 80. While in developed regions of the World, women’s risk of maternal death is 1 in 3,800 (WHO May, 2012).

The Millennium Development Goal on improving maternal health calls first for a 75% reduction by 2015 in the maternal mortality rate from 1990 levels for Nigeria (using estimates from the country’s 2008 Demographic and Health survey, which are slightly lower than UN estimates) a reduction to 250 maternal deaths per 100, 000 live births, and second for 100 percent of deliveries to be assisted by a skilled birth attendant.

According to Nigerian Government, estimate, 2010, it is possible that the country can reach the maternal mortality target by 2015, but it will need dramatic and sustained progress in the year 2018 (National planning Commission 2010, P.31).

There is existence of disparity among regions in Nigeria. There are increases maternal mortality rates in the Northern Nigeria than in the Southern part of Nigeria, perhaps because the southern region is weather and has abundant mineral and natural resources. According to Seye Abimbola et al 2012, the extremely poor North East has an estimated maternal mortality rate of 1,549, and it is believed to be more than five times the global average.

It is also believed that poverty, lack of investment in health systems, low educational levels, and infrastructure have each contributed to the disparity. Also cultural factors that give women limited mobility and contacts with the formal health care system and little say in household and personal decision also contributes to disparity in Nigerian southern states. There have been instances of leadership on maternal health in the north. Kano was the first state in Nigeria to introduce free maternal care in 2003, but have not always been sustained.

Currently, terrors attacks by the extremist group of Boko Haram have forced many health and development implementers to shut down or scale back operations in the North and public health experts can afraid that prolonged insecurity might spoil the gain and efforts of the last decade.

1.2       Statement of the Problem

The United Nations Millennium Development Goal (MDG) number five on maternal health aims to decrease the number of women dying during pregnancy and child birth by three quarters between 1990 and 2015. In order to meet up with the goal, it is estimated that an annual decrease in maternal mortality of 5.5% is needed. However between 1990 and 2010, the annual decline was only 1.7% in the sub-Sahara region, (WHO 2012). Therefore, many countries in sub-Sahara Africa will not be able to achieve the goal by the end of this year 2018.

Despise the availability of antenatal care services in the hospital, many pregnant women that have pregnancy related conditions do not receive preventive and curative services due to under utilization of antenatal care and delivery services. As a result of that, they come to labour when they already have untreated medical conditions that leads to poor outcomes such as maternal death, disability or long term illness which affect our public health and the entire socio-economic development negatively.

A preliminary review of antenatal delivery records Olabisi Onabanjo University Teaching Hospital (OOUTH) Sagamu Nigeria, revealed that only 47.6% of booked pregnant women subsequently delivered there. (Lamina M.A, Sule-Odu A.O, and Jagun E.O 2008). This observation has motivated a thought to carryout this study. The figurers of maternal and prenatal mortality which are the indicators of effective ANC Service delivery and attendance by women to clinic, are not encouraging in our country, Nigeria and sub Sahara Africa.

One of the major public health concerns in this 21st century is the quality of antenatal care and delivery services. The approach to ANC also emphasizes the quality of care than quantity. (Olufumilayo et al, 1998). There is also need to find out the level of ANC and delivery service utilization and the quality of ANC services. It is believed that if poor quality care services are rendered to antenatal mothers, the tendency is that there may be reduction in ANC visits that will lead to decrease in the level of ANC service and delivery utilization.

In a study in Nigeria, according to WHO 1999, it was reported that the key interventions to save new born lives are mostly possible through the existing health system but coverage is extremely low even much lower than most other African Countries.

This study therefore sought to establish the factors which influence the utilization of ANC and delivery services by the study population in Obollo-Afor cottage Hospital/Primary Health Care Center and Orba Health Center in order to improve the uptake of these services. This will subsequently improve the health of the mothers, babies and the community at large.

1.3       The Purpose of the Study

The purpose of this study was to carry out a research on the utilization of antenatal care and delivery services among women of reproductive age in Obollo-Afor and Orba Primary Health Care Center, in Udenu Local Government Area of Enugu State Nigeria.


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