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1.1       Background of the study

Maternal and Child Health (MCH) services embrace all the services for mothers throughout the child bearing age, that is 15–49 years of age, and also services for children from conception through adolescence It is targeted to reduce by three-quarters, between 1990 and 2015 child mortality rate. Maternal health is the health of women during pregnancy, childbirth and the postpartum period and maternal health care services are antenatal care (ANC), delivery care and postnatal care (PNC) services Approximately 536,000 maternal deaths occur annually, of which over 95% occur in sub-Saharan Africa and Asia. Africa has the highest burden of maternal mortality in the world and sub-Saharan Africa is largely responsible for the dismal maternal death figure for that region, contributing approximately 98% of the maternal deaths for the region. The lifetime risk of maternal death in sub-Saharan Africa is 1 in 22 mothers compared to 1 in 210 in Northern Africa, 1 in 62 for Oceania, 1 in 120 for Asia, and 1 in 290 for Latin America and the Caribbean. Nigeria is a leading contributor to the maternal death figure in sub-Saharan Africa not only because of the hugeness of her population but also because of her high maternal mortality ratio. Nigeria's maternal mortality ratio of 1,100 is higher than the regional average. With an estimated 59,000 maternal deaths, Nigeria which has approximately two percent of the world's population contributes almost 10% of the world's maternal deaths (WHO).

Scientific evidence has clearly established the inverse relationship between skilled attendants at birth and the occurrence of maternal deaths. Thus, the considerable variation in the maternal mortality estimates between different locations within the same region can be attributed, to a large degree, to the differences in the availability of and access to modern maternal health services. The use of maternal health services also contributes to neonatal health outcomes as the health of the mother and the newborn is closely linked. Maternal complications in labor, for example, carry a high risk of neonatal death. Three-quarters of neonatal deaths occur in the first week, and the highest risk of death is on the first day of life. Furthermore, the main direct causes of neonatal death, globally, are preterm birth (28%), severe infections (26%), and asphyxia (23%). This epidemiological picture underscores the contribution of the delivery process to neonatal deaths.

While available evidence indicates limited benefit from traditional antenatal care services, focused antenatal care provides opportunity for early detection of diseases and timely treatment. It also provides opportunities for preventive health care services such as immunization against neonatal tetanus, prophylactic treatment of malaria through the use of intermittent presumptive treatment approach, and HIV counseling and testing. Furthermore, antenatal care exposes pregnant women to counseling and education about their own health and the care of their children. Thus, antenatal care may be particularly advantageous in resource-poor developing countries, where health seeking behavior is inadequate, access to health services is otherwise limited, and most mothers are poor, illiterate or rural dwellers. With the strong positive association that has been shown to exist between level of care obtained during pregnancy and the use of safe delivery care, antenatal care also stands to contribute indirectly to maternal mortality reduction. According to the 2003 Nigeria Demographic Health Survey (NDHS), 37% of women who had births within the five years prior to the survey received no antenatal care for their most recent delivery while only 35.2% were assisted at delivery by a skilled attendant.

Several studies have assessed the individual and household determinants of utilization of maternal services. These studies have not yielded a consistent pattern of relationships between service utilization and individual and household predictors. In some cases, even when a strong association has been reported, such as in the case of the positive relationship between education and the use of skilled health attendants at birth, the extent and nature of the relationship are not uniform across social settings. For example, whereas studies in Peru and Guatemala showed that women with primary level education were more likely to utilize maternal health services compared to those without any formal education, some studies in Thailand and Bangladesh did not record any significant difference between the two educational groups. Distances to health services and rural locations have been generally reported to be strongly and negatively associated with the use of maternal health services. Some studies conducted in Turkey and southern India, however, did not show any significant difference in the use of antenatal care between urban and rural women. Association between age and service utilization has also been inconsistent across studies. Whereas many studies found a positive correlation between age and the use of skilled attendants at child birth, others have found a curvilinear relationship. Religion has also shown variable pattern of association with service utilization, with significant association in some settings but not in some others. In contrast, parity has been consistently shown to be negatively correlated with the use of skilled attendants. A number of studies have reported positive association between economic status and use of medical settings for delivery whereas others have not found such an association.

One important inference from the review of existing literature is that the role of individual and household factors differs from one geographic and social setting to another. Thus, as several authors have aptly noted, the determinants of maternal health care service utilization vary across and within cultures.

It is reasonable to assume that utilization of maternal health services depends on individual and household factors, as well as factors operating at the community or policy levels. The review of extant literature however shows that very few studies have gone beyond individual and household factors to consider factors at the community and higher levels. The implication of this omission is that some determinants are inadvertently missed, leaving a serious research and programmatic lacuna. Secondly, failure to consider the role of factors operating beyond the household level in service utilization may result in serious bias in the estimates. Individuals are nested within families, which are in turn nested within communities. Methodologically, it is important to take this nested structure into account. This demands the use of multilevel modeling, which would calculate the standard errors more accurately and reduce the chance of misestimating the significance of variables, as some of the assumptions inherent in traditional regression methods are not valid for nested data.

Very few population-based studies have been carried out in Nigeria regarding determinants of maternal service utilization; most maternal health studies in the country have been institution-based. Most of the population-based studies were small-scale research, focusing on a handful of communities, usually small-sized rural communities. Their geographic scope limits the applicability of their result on a large scale, particularly considering the complex multi-ethnic setting of Nigeria. In addition, most did not control for important confounding variables. Drawing from a nationally representative survey, this paper seeks to address the identified research gaps by examining the effect of individual, household, community and state-level factors on maternal care services utilization and employing strong analytical procedures. Specifically, we investigate the patterns and determinants of the utilization of the three dimensions of pregnancy-related care - ante-natal, delivery, and post-natal services.

Maternal and child healthcare services are very important for the health outcomes of the mother and that of the child by ensuring that both maternal and child deaths are prevented. Many health programs have been launched in the country in last two-three decades for women and child health care. Health care utilization overall, and for maternal health specifically, has improved in Nigeria mainly due to NRHM2 but Maternal mortality and morbidity continue to be high despite the existence of national programs which could be due to sub optimal levels of utilization of services3-4 especially amongst the rural poor and urban slum population.5 Studies have also found the need for such services is greatest, i.e., among disadvantaged populations. 6-9 Various studies conducted worldwide and in Nigeria have recognized socio-economic, demographic factors and service delivery environment as important determinants for the use of maternal health services.10-16 Uttar Pradesh is one of the eight states which is home to 43% of Nigeria urban poor with rates of utilization of maternal health services far below the national average. Hence there is a distinctive need of under standing the factors affecting the use of maternal health services. However, scarce research is available in the context of Uttar Pradesh of Nigeria.

1.2       Statement of problem

The Nigerian health care system’s ineffectiveness and inefficiency are largely due to poor budgetary allocation and mismanagement of meager resources allocated to health care, according to NHIS (2010). High out-of-pocket expenditures and poverty are the main barriers identified in accessing health care services in Nigeria (NHIS, 2010). According to the WHO, Nigeria has a MMR of 630/100,000 live births, although there are disparities across the country’s six geopolitical zones (NHIS, 2010). This rate is high compared to other African nations. South Africa has a MMR of 300/100,000; Namibia, 200/100,000; Algeria, 97/100,000; and Egypt, 66/100,000 (WHO, 2005). According to the Jigawa State Ministry of Health (2010), the MMR for the state in 2010 was 1000/100,000 live births.

Over 80% of the Nigerian population lacks any form of insurance. These individuals bear the most significant burden of health problems such as malaria, hypertension, diarrheal diseases, whooping cough, antepartum hemorrhage, puerperal sepsis, anemia, and acute respiratory tract infections (NHIS, 2010). Because pregnant women are the most vulnerable group within this population, it is critical to address their needs, access, and desired outcomes. A study conducted in Sierra Leone showed an increase in utilization of hospital services by pregnant women participating in a free

MCHS program (De Allegri et al., 2011). However, authors of another study in Burkina

Faso observed no effect on utilization, despite the user fee exemption (Treacy &

Sagbakken, 2015). Bado et al. (2015) demonstrated an increased demand for treatment and delayed reduction to access to care with user fee exemptions in community case management of malaria in rural Burkina Faso. 

Although there are studies on free health care and pregnancy outcomes in other countries, there is, as of yet, no study on whether Jigawa State’s free health care program has any impact on utilization, particularly on the number of antenatal visits in the state. Many experts feared that both federal and state governments in Nigeria, including donor agencies, might not be able to sustain free maternal and child health (MCH) services across the country (Nove, Hulton, Martin-Hilber, & Mathews, 2014). Others contended that such programs might compromise quality, as the money realized from services is used for daily activities that promote quality of services (Amnesty International, 2011).

Researchers have yet to study the impact on health care utilization of the NHIS-

MDGs and free maternal health services in some states across the country (WHO, 2014b). Amid dwindling resources, the MMR (1000/100,000 live births) has remained high in the state. I addressed this issue by examining the utilization of maternal and child health care services as measured by ANC visits in Jigawa State, Nigeria.

1.3       Objectives of the study

The aim of this study is to establish determinant factors in the utilization of maternal and child health care services among women of reproductive age in Miga Local Government, Jigawa Sate.

1.3.1 Specific Objective

To establish factors that determine the use of all maternal and child health care services

To find out the occurrence of maternal and child health care service among in Miga Local Government, Jigawa Sate.

To investigate the extent of utilization of health facilities among in Miga Local Government, Jigawa Sate

1.4       Research Question

  • What factors influence utilization of maternal and child health care services in Jigawa State, Nigeria?
  • What factors influence the occurrence of maternal and child health care service among in Miga Local Government, Jigawa Sate?
  • What extent use of utilization of health facilities among in Miga Local Government, Jigawa Sate?

1.5     Significance of the study

Maternal mortality rates in Miga Local Government, Jigawa Sate remain high and this study aims at contributing to better understanding about utilization of maternal health care services by expectant women in Miga Local Government, Jigawa Sate. 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 KDHS which interviewed 8444 women of age 15 to 49, 1039 from Miga Local Government, Jigawa Sate, 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 Miga Local Government, Jigawa Sate only; therefore, its findings and conclusions cannot be generalized to other provinces in the country.

 1.8      Operational of Definition of Terms

Antenatal care: Services rendered to a pregnant woman by health care providers (doctors, nurses, and midwives), which include physical examination, immunization, disease screening, health education, antimalarial (sulphadoxine and pyrimethamine combination), and hematinics (fersolate) drug provision, and treatment. It usually begins the first trimester and extends to the third trimester.

Antenatal care visit: A visit to health facility by pregnant mothers for the purpose of a safe pregnancy and delivery (WHO, 2006).

Autonomy: The degree to which a woman can assert her rights on issues of reproductive health.

Health care utilization: Health care services used by those in need of those services (Segen, 2005).

Home deliveries: An instance of giving birth at home rather than in a hospital (UNICEF, 2014).

Institutional deliveries: Hospital deliveries (UNICEF, 2014).

Lifetime risk: The probability of a woman dying from childbirth in her lifetime.

Maternal death: “The death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by pregnancy or its management, irrespective of the duration and site of the pregnancy, but not from accidental or incidental causes” (WHO, 2013).

Maternal mortality rate: “Annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management, excluding accidental or incidental causes” (WHO, 2013).

Maternal mortality ratio: Number of maternal deaths per 100,000 live births in a given year (WHO, 2013).

Neonatal mortality rate: “Number of deaths in the first 28 days of life per 1000 live births” (WHO, 2010).

Out-of-pocket payment: Cash payment made by patients at the point of receiving health care services (MOH, 2010).

Parity: “Number of times a woman gave birth to a twenty-four weeks or above fetus regardless of whether alive or stillborn” (UNICEF, 2014).

Traditional birth attendant: Otherwise called a local midwife; usually an old woman who provides pregnancy and child-care in the community

Health worker: Trained personnel (doctor, nurse, midwife, or community health extension worker) who offers health care services.

Skilled birth attendant: A health worker who provides health care services during pre- and postnatal periods (UNICEF, 2014).

User fee: A mandatory payment made by patients for receiving health care services (MOH, 2010).

Use Fee Exemption Policy: A deliberate government plan to provide health care services free for patients (MOH, 2010).

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