Titilayo Olaitan, Ifeoma P. Okafor, Adebayo T. Onajole, Olayinka A. Abosede
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
- femiolaitan1@gmail.com (TO); ipokafor@cmul.edu.ng (IPO)
Discussion
ANC saves the lives of mothers and babies by promoting and instituting good health before delivery and during the early postnatal period. This study found that the utilization of ANC was generally high. This proportion is higher than that reported in NDHS 2013(61%) [15]1 but lower than the proportion reported in India (99%), Kenya(89%), Southeast Nigeria (97%) [12],[32±33]. It is almost similar to figures reported in Ibadan, another city in southwest Nigeria where utilization was 78% [34]. This result may be attributed to the high proportion of women who had formal education and the fact that the study was carried out in an urban community where there is easy access to mass media. The majority (74.3%) that utilized ANC services did so at public health facilities which are in line with practices in Ilorin; North central Nigeria [35]. The reason for this is not farfetched as ANC services are usually offered at a subsidized rate in public health facilities. This may account for the long waiting time and poor attitude of health workers recorded in some studies as a reason for non utilization of maternal and child health services, as this preference will stretch the public facilities with negative consequence for utilization [26],[32].
The educational and employment status of respondents and their spouses were significant factors influencing the utilization of ANC services at health facilities. This finding was consistent with figures from our NDHS and other parts of the country [15],[26],[33]. This might be due to the fact that educated couples are better informed to make informed choices. Education provides a woman with a unique opportunity to improve her own health and that of her
children. From the results, the predictive effect of higher levels of education on ANC utilization was pronounced, thus emphasizing the importance of formal education for the girl child. There was a higher institutional delivery rate than reports from other studies done in Kenya (47%), Ethiopia (32%), Nigeria (Kaduna Northwest) (28%) and NDHS 2013 (30%) [10],[14]. [15],[33].1About 40% of the respondents did not have institutional delivery, a proportion, which is a bit higher when compared with other parts of Nigeria [5],[14]. A study done in Ife Southwest Nigeria, reported non-facility delivery rate of 24% among pregnant women, while 70% home delivery rate has been reported in Northern Nigeria [25],[36]. Out of the 40% who delivered outside the health facility, only very few were delivered by skilled birth attendants.
High morbidity and mortality is associated with unskilled delivery [37]. Similar to reports from another study [37], perceived quality of service was the most important factor which influenced the choice of institutional delivery. The significance of maternal age in the utilization of institutional delivery has also been observed by other authors [10],[24],[33]. The youngest age group were the lowest proportion of users. Older women probably through exposures to health education during previous pregnancies were likely to make better choices. The younger women could be naive to take instructions and opinions from significant influencers like mothers and mothers in law especially in
situations of low male involvement. It might also be because they are often less socio-economically empowered and as such, prefer facilities providing care at minimal cost. On further analysis, this apparent effect of age was downplayed.
Marital status was also a significant factor with the unmarried women having the lowest proportion of users while the married, educated and employed women have the highest proportion. The stigma and vulnerability associated with pregnancy outside wedlock were likely to deter unmarried respondents from having their babies in the health facility. Financial incapacity and lack of social support for these women with unwanted pregnancy have also been
implicated [38±39]. The role of poverty from unemployment is also evident in this study by their significantly lower utilization of institutional delivery. The study has shown the effect of male educational and financial empowerment on institutional delivery. This is particularly important in the African setting as the male is usually the bread winner and major decision maker in health. There was an increased utilization with increasing number of children. This
is consistent with report of a similar study done in southeast Nigeria [33]. It may be that these women experienced obstetric complications thereby prompting them to choose institutional delivery.
Of the 371 respondents, 78% received post natal check-up at least once during the six weeks following their last confinement. The utilization of PNC services was slightly higher than that found in Gondar Zuria district, Ethiopia (66.8%), and Lagos (66.2%) but much higher than the 35.3% found in Kaduna Northwest Nigeria and<10% reported in Anambra, Southeast Nigeria [17],[33],[38],[40±41]. The urban nature of the study may explain the high utilization of PNC, though for many, the actual visits still fall short of the minimum of four postnatal contacts recommended
for all mothers and newborns by the WHO [42]. The significant association between socio-demographic characteristics and PNC service utilization is in line with previous studies [38],[40±41]. This further buttresses the importance of female education and empowerment.
Other factors which increased PNC utilization were being discharged at least 24 hours after delivery and minimum of four ANC visits. These visits allow the women to receive information on positive maternal and child health-seeking behaviour. With full implementation of the new WHO guideline on increased ANC visits [19], the PNC utilization is likely to improve, thus preventing more maternal and newborn morbidity and mortality. According to the non-users of ANC, the major deterrent was financial, thus denying them the benefits of proper ANC. Mothers who did not utilize PNC saw no reason for it since mother and child appeared healthy. This reason has some socio-cultural backgrounds as it is a normal practice in many parts of the country for a new mother to be confined to the house for the first 40 days post-delivery unless for extremely important reasons.
One of the services received by respondents during PNC services in the last pregnancy was family planning counseling but surprisingly, this knowledge did not influence their family planning use as only about a third were current users at the time of study. This proportion is low though higher than the report of NDHS 2013, in which prevalence of modern method of contraceptive use was just 10% [15].A study conducted in Ethiopia showed that women who discussed about family planning issues with their husbands/partners were 10 times more likely to utilize family planning services than those women who do not discuss family planning issues [42]. Majority of non users were afraid of side effects, or their spouses did not support family planning use. Family planning programmes need to address these issues through carefully designed messages and male involvement. The positive influences of number of living children and maternal education on the practice of family planning were revealed in this study. Some other authors had made similar observations [42±44].
Only about half of the respondents initiated breastfeeding early and even a lower proportion practiced exclusive breastfeeding. Though the proportion almost doubled the national average, it is far from satisfactory as the benefits of exclusive breastfeeding cannot be overemphasized. Diarrhoea affects child well-being and creates considerable demand for health services [45]. WHO stated two simple and effective treatments for the clinical management of acute diarrhoea-the use of low concentration oral rehydration salts (ORS) and routine use of zinc supplementation
[46]. Many of the women used ORS but the use of zinc was just 46.4%. The awareness of Zinc supplementation in diarrhoea appears to be low among them, this has negative implications for child survival. Child health outcomes remain one of the most important parameters for measuring the overall social and economic well-being of a country. The higher utilization of childhood preventive healthcare services among respondents may be attributed to the minimal costs attached to these services especially in public health facilities, more than curative services.
Many mothers were also likely practicing home treatment, hence the low facility consultation for illnesses. Other studies in urban Lagos also recorded higher utilization of preventive services [47±49]. Again the significance of maternal education was manifested in the utilization of child healthcare services. Children whose mothers are not educated are far less likely to be fully vaccinated than children whose mothers had more than secondary education (p = 0.002). They are also less likely to be taken regularly for growth monitoring (p<0.001) or for treatment
of illness (p = 0.029). This is consistent with findings from Uganda, Nepal, NDHS 2013 and Lagos [11],[15],[24],[50],[51]. With an increase in the number of children, the rate of utilization dropped indicating that grand multiparous women were less likely to utilize health services for their children. Surprisingly, more of them had their babies in the health facility. This may be a case of `perceived expertise’ and brings to light, the importance of continuum of care and integration of maternal and child healthcare services. This will encourage good health-seeking behaviour for their children. It could also be financial as documented in other parts of Africa [52] inferring that household income and expenditure can predict utilization of child healthcare services. It was also shown that good maternal healthseeking
behaviour (having at least four ANC visits) increased good child healthcare service utilization.
Limitations of the study
The trained community health workers recruited as interviewers may have introduced some respondent-reporter bias.
The study was conducted in a sub-part of Lagos State and so results may not be generalized to the country.
A qualitative aspect could have been included to gain more insight into the subject.
Conclusion
Though the utilization of some of the life lines (ANC, health facility delivery, PNC) by the respondents was high, lower rates were recorded for the utilization of family planning and the exclusive breastfeeding. Delivery at TBA centres was common. Only few women did not utilize any of the specified lifelines. Meanwhile utilization of preventive child health care services was better than curative services. Socio-demographic, socio economics factors and health-seeking behaviour were found to play significant roles in the utilization of maternal and child health
services. The significance of maternal education in predicting utilization was very prominent in this study. These should be put into consideration in thedesign of appropriate interventions to further improve utilization. Further research, especially on the services with low utilization rates is needed to make the dream of the SDGs achievable.
Recommendations
Programs to further enlighten women on the benefits of these life lines especially family planning and breastfeeding should be implemented. The well utilized maternal and child services like antenatal care and immunization can be used for this purpose. Furthermore the education of the girl child should be encouraged. Education enhances the economic status of mothers; it empowers them, increases the level of awareness, and builds independent decision making capacity in them. The inclusion of men as targets of family planning campaigns will have an important influence on its acceptance and usage. Interventions should focus on young women, those with low level of education and the poor. Spouses’ education and involvement should also be vital components of intervention programmes to improve utilization. A qualitative approach to this topic is also recommended in order to gain more insight.
Supporting information
S1 File. Abbreviations.
(DOCX)
S2 File. Questionnaire.
(DOCX)
Acknowledgments
Our sincere gratitude goes to the data collectors, the study community and their leaders for their co-operation.
Author Contributions
Conceptualization: TO IPO.
Data curation: TO IPO.
Formal analysis: TO IPO.
Funding acquisition: TO.
Investigation: TO IPO.
Methodology: TO IPO.
Project administration: TO IPO.
Resources: TO IPO ATO OAA.
Software: TO IPO ATO OAA.
Supervision: IPO ATO OAA.
Validation: TO IPO ATO OAA.
Visualization: TO IPO.
Writing ± original draft: TO IPO.
Writing ± review & editing: TO IPO ATO OAA.
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