Ending preventable maternal and child deaths in western Nigeria: Do women utilize the lifelines?

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)

Abstract
Introduction


Nigeria which constitutes just one percent of the world population, accounts for 13% of the world maternal and under-five mortality. Utilization of health care services has been an important determinant of maternal and child outcomes. The vast majority of maternal and child deaths could be prevented if women utilize the available life lines. The study objective was to determine utilization of maternal and child health care services among women of
child bearing age in Western Nigeria.


Methods

A community based, cross-sectional study was done in Oshodi/Isolo Local Government. Area among women of childbearing age (15-49 years) with at least one child under five years. Multistage sampling was used to select 371 respondents. Data was collected with a structured, pretested, interviewer administered questionnaire and analyzed with Epi info 3.5.1. Summary and inferential statistics were done. Level of significance was set at 5% (p<0.05).

Results

Of the 371 respondents interviewed, the health facility was used for antenatal care (74.3% n = 276), delivery (59.9% n = 222), postnatal services (77.9% n = 289), family planning services (28.8% n = 107), immunization (95.1% n = 353), growth monitoring (77.4% n = 287), nutritional services (64.7% n = 240) and treatment of childhood illness (49.6% n = 184). Only 31.5% (n = 117) of the respondents practiced exclusive breastfeeding and 82% (n = 263) of the mothers used oral rehydration solution for diarrhoea management. Maternal education significantly influenced utilization. In addition maternal age, employment status, number of children, spouse employment and educational status played significant roles.

Conclusion

Utilization of maternal and child health services among respondents was above the national average but not optimal, especially family planning services, exclusive breastfeeding and

Introduction
Every day, approximately 830 women die from preventable causes related to pregnancy and
childbirth[1]. For every woman who dies in childbirth; a lot more suffer injury, infection or
disease. Globally an estimated 289, 000 maternal deaths and maternal mortality ratio (MMR)
of 210 maternal deaths per 100, 000 live births occurred in 2013 [2]. Nigeria accounted for 13%

of all maternal deaths in 2013 [3]. “Similarly, every single day, Nigeria loses about 2,300 under-
five year olds and 145 women of childbearing age” [4]. This makes the country the second larg-
est contributor to the under—five mortality rate and maternal mortality ratio in the world.

Maternal, newborn and child healthcare service utilization remain important indicators for

monitoring the progress of maternal and child health outcomes. Antenatal Care (ANC), deliv-
ery at health facilities with skilled professionals and postnatal care (PNC) reinforce the timely

management and treatment of complications to reduce maternal deaths[5–7]. Family planning
is another important component of the Safe Motherhood Initiative to reduce maternal deaths
in developing countries[8]. Also reduction in under five mortality can be obtained by increase
in use of vitamin A, immunization, oral rehydration therapy, long lasting insecticidal nets
(LLINs), exclusive breastfeeding and treatment of common childhood illness (malaria) [9].
These interventions can be regarded as life lines as they serve as means through which lives of
mothers and children can be saved or preserved when utilized.
However, utilization of these services remain low in Sub-Saharan Africa (SSA) and Nigeria
[10–14]. According to National Demographic and Health Survey (NDHS) 2013 report, 63% of
women received antenatal care from a skilled provider, 38% had skilled delivery and only 10%
were currently using modern family planning. The same report indicated that under five
mortality rate was still high at 128 deaths per 1000 live births; only 25% of children age 12-25 months were fully immunized and only 17% exclusively breastfed. These figures were much
lower for rural than urban areas [15]. Studies have also revealed a very low usage of post natal
care services in the country [16–17]. Maternal complications and perinatal mortality are highly
associated with under-utilization of antenatal and delivery care services. The provision of
skilled care before, during, and after childbirth saves lives of women and it also increases the
chances of having healthy infants [1],[18]. World Health Organization (WHO) analysis shows
that if 90% of women received ANC, up to 14% or 160,000 more newborn lives could be saved
in Africa [19]. Also an estimated 17.1 million children’s lives have been saved since 2000,
largely due to increased vaccination coverage against highly contagious viral diseases [20].

Over 800,000 children’s lives could be saved every year among under fives, if they were optimally breastfed[21]. Many more deaths could be prevented if all the maternal, newborn and child health (MNCH) care services were optimally utilized between 2016 and 2030, in order to meet the Sustainable Development Goal (SDG) 3 [22].

Despite the existence of national programs for improving MNCH in Nigeria, the mortality
and morbidity rates are still high as the progress of decline is slow [23]. The benefits of health
care seeking and positive health behaviours are related strongly in settings and subgroups
where socio-economic and public health resources are constrained[24]. “

The utilization of health care services is a complex phenomenon related to the availability, quality, cost of services, social structure, health belief and characteristics of the users”[25–26]. The extent of use.

varies from one community to another and also varies from urban to rural areas[13],[14],[27].
It has been found that in developing countries, attainment of education and having a paid job

empower mothers to utilize maternal health services[28]. The survey done in Nepal demon-
strated that sex of the child, household income, mother’s education, partner’s employment,

and distance to health care provider all play various roles in determining health service utiliza-
tion for children under age five[29].

From the fore-going, this study was undertaken to determine the utilization of maternal
and child health care services and to identify factors which affect utilization among women of

child bearing age in Southwest Nigeria. This will generate data for the sub-region and influ-
ence interventions and policies where necessary.

Materials and methods
Study area


Lagos State is located in the South-Western part of Nigeria. The State has a population of over
21million [30]and is made up of 16 urban and 4 rural Local Government Areas (LGAs).
Oshodi-Isolo is one of the urban LGAs located in the North East of the State. It comprises 7
wards. According to 2006 population census, the total population of Oshodi-isolo was put at
621,509. The 2015 projected population is well over a million (1,506,399).The MMR of

Oshodi-Isolo LGA is 443 per 100,000 [31]. The inhabitants are of varying educational, religious, occupational and ethnic backgrounds. The area is both residential and commercial. Formal and informal health care services are available in the study area. There are primary health

care (PHC) centres, health posts, private clinics, pharmacies, patent medical stores, as well as
complementary and alternative sources of services such as Traditional Birth Attendants
(TBA), herbalist and spiritual homes. Many residents reside within five kilometres from formal
health facilities that provide maternal and child healthcare services.

Sample size and sampling procedure


The study was a community based, descriptive cross-sectional study among women of child bearing age (15-49 years). Using the Cochran formula for calculating sample size for descriptive studies in populations>10, 000 (n = z 2pq/d2), an initial minimum sample size of 344 was calculated based on expected five percent error margin, 95% confidence interval and estimated proportion in the population who have particular characteristic of interest) of 0.65 from a previous similar study. 15 However, to compensate for improperly filled questionnaires; the calculated sample size was increased by 10% to get the final sample size of 382 for the study.

Multistage sampling method was used to select the respondents. The first stage involved selection of two wards from the seven wards in Oshodi/Isolo by simple random sampling (Afariogun and Igbehinadun wards). The second stage was the selection of streets from the list of all the streets in the two selected wards. There were between 20-30 streets in Afariogun and

Igbehinadun wardsand 10 streets were selected from each of them by simple random sampling. The third stage involved selection of houses in the selected streets using systematic sampling method. The average number of houses on each street is 40. The calculated sampling interval was two. The starting point on each of the streets was chosen by simple random sampling method and every second house was subsequently selected. The fourth stage involved selection of the eligible household from the houses using simple random sampling. One household in every house was selected. The last stage involved selection of respondents by simple random sampling (one eligible woman in each household) until the desired sample size was met.

Data collection and quality checking


Data was collected using a structured, pretested, interviewer-administered questionnaire. Each
interview lasted for about 20minutes and the data collection process lasted for one month. The

questionnaire was designed to elicit information on socio demographic characteristics, utilization of maternal health care services (ANC, delivery, postnatal services and family planning) and utilization of neonatal and child health care services (immunization, growth monitoring, treatment of illness and nutritional services). Thirty questionnaires were pretested in Alimosho, another urban LGA in Lagos State and amended as appropriate. The interviewers were five trained voluntary community health extension workers (CHEWs) working in one the health centres in the Osodi-Isolo LGA. The interviews were conducted in English and Yoruba languages. The interviewers were frequently supervised on the field by the principal researcher to monitor data collection and provide necessary feedback. Data were entered manually into the Excel software twice by one of the co-researchers and a data entry manager, then exported to EPI info version 3.5.1 for analysis. Descriptive statistics such as frequencies and proportions
were computed to describe the study population and variables. Inferential statistics (Chi square test) was done and level of significance was set at five percent (5%).

Ethical consideration


Ethical approval was obtained from the Health Research and Ethics Committee (HREC) of
Lagos University Teaching Hospital (LUTH) and assigned number ADM/DCS/HREC/APP/228 Appropriate community entry was done through the community leaders. Participation in the study was on a voluntary basis and informed written consent was obtained before the interview. Confidentiality of the information was assured and maintained by using an anonymous questionnaire.


Results

A total of 382 questionnaires were administered but 371 were eventually valid for analysis. The study showed that 41.5% of the respondents were in the age group of 26–35 years with a mean age of 29±5years. Majority (92.5%) of the women were married and of Yoruba tribe (60.4%). A little above one third of them had two children. Seventy percent of them reside at a distance of 20 minutes travel time from the nearest health facility that renders maternal and child healthcare services. Only one quarter (25.3%) were educated beyond the secondary school level. Majority (80.6%) were employed with about 37.4% earning less than N20, 000 (66 US Dollars) monthly. (Table 1). Large proportions (60.9%) of the respondents’ spouses were between 31 to 40 years, many of whom had post secondary school education (44.2%). About 90.6% of them were gainfully employed.


Maternal health care utilization

Majority of the respondents received ANC in their last pregnancy from the health facilities (74.3%), out of which 65.6% did so in public health facilities. For those who had ANC at health facilities, approximately 48% registered in their second trimester and two thirds (65.9%) of the women visited the clinic four or more times while the remaining one third (34.1%) visited the clinic less than four times(Table 2).
Most (59.7%) of the women had institutional delivery while 26.7% delivered at TBA centres and 7.5% at home. Out of the 95 respondents who did not deliver at health facilities, majority (68.5%) were delivered by TBAs while 14.4% were delivered by nurses. The quality of care (37.5%), nearness to home or work place(34.5%) and cost of services (27.5%) were the most frequent reasons for choice of place of delivery (Table 2).
Seventy eight percent utilized PNC in the last confinement. Majority (58.8%) made only one PNC visit after delivery and about half of them went in the 5th or 6thweek (50.2%). Most (56.8%) of the respondents who delivered at the health facilities were discharged at/after 24 hours post delivery. Newborn check up (98.6%), counselling on breastfeeding (92.0%), physical examination (74.4%), and family planning (73.7%) were the most frequently utilized services.

Reasons for non attendance of antenatal and postnatal care


Only few (7.3%) did not receive ANC. Financial constraint (37%) was the major reason given,
followed by the fact that they felt that they did not need to go since they were not sick (33%).
The major reasons for not attending postnatal care were no reason (mother and child are
healthy, so no reason for PNC) (61.0%), ignorance (19.5%) and long distance (11%). (Table 3)
Majority (71.2%) of the respondents were not currently on modern family planning
method. For the 28.8% who were currently using modern family planning; IUCD (32.7%),
injections (24.3%) and implants (22.4%) were the commonly used ones. The decision to use
was made by the respondents mostly (48.6%) and jointly by the respondents and their spouses in 36% of the cases. For those that did not use modern family planning method, the most frequent reason given was fear of side effects (41.7%).

Utilization of child health care services


Almost all (98%) the respondents’ breastfed their babies, 52.9% of them commenced within 30 minutes postpartum. The proportion of respondents who practiced exclusive breastfeeding (EBF) was 31.5%. The mean duration for EBF was 5.57±1.125 months. Eighty six percent of the children had previously suffered diarrhoea since birth and the last episode was treated using ORS (82.4%), Zinc tablet (46.4%) and antibiotics (40.4%).

Majority (95.1%) of the respondents have utilized the health facilities for immunization services, growth monitoring (77.4%), nutritional counselling (64.7%) and treatment of illness (49.6%). Most of the respondents (96.6%) reported that their children were fully immunized for age but on sighting the immunization cards, this proportion dropped to 81%, and so only

19% were not immunized. Seventy eight percent utilized the growth chart for growth monitoring but majority (65.2%) reported that the progress of the child was not discussed by the health worker after recording the weight on the chart (Table 4)


Factors associated with maternal and child health care services utilization


Higher maternal educational level and employment status of the women significantly increased utilization of ANC in health facilities. Also paternal educational level and employment status significantly increased utilization of ANC at the health facility (p = 0.016, <0.001). There was a significant association between age and use of delivery services at the health facility (p = 0.027). Other factors that also significantly influenced utilization of delivery services at health facilities were marital status(least among single mothers), maternal educational level and employment status. A statistically significant higher proportion of respondents whose spouses were employed and had at least secondary education utilized institutional delivery (p 0.001). (Table 5)

There was a significant association between utilization of PNC and number of ANC visits. Women who had minimum of 4 ANC visits (p = 0.007) and women who were discharged at least 24 hours after delivery in a health facility (p = 0.028) utilized PNC more. The highest proportions of modern family planning method users were the older, higher educated women and those with at least three to four living children. Utilization of both immunization and growth monitoring services increased as maternal age increased with a statistically significant difference (p = 0.061, 0.008). Also, there was a significant association with maternal education (p.0.002, <0.0010). Older and better educated women utilized the health facilities for treatment of illness for their children more than the younger and less educated ones and the association was significant (p = 0.007, <0.001). (Table 6).Respondents who received ANC at health facilities, delivered there and utilized PNC services were more likely to utilize the child health services. A higher proportion of respondents

who received ANC at health facilities, and those who delivered at health facilities utilized both growth monitoring and curative services. These associations were statistically significant. Utilization of PNC was not significantly influenced by growth monitoring and curative healthcare service utilization though there was better use of these services among PNC users.


The multivariate analysis identified maternal schooling beyond the primary school level and spouse employmentas significant and independent predictors for the use of antenatal care services. Using ‘no formal education’ as a reference category, respondents with secondary education were six times more likely to use formal ANC (OR = 6.02, 95%CI 1.96–18.41). Similarly, those with post-secondary education were 32 times more likely to use formal ANC than those who had no formal education (OR = 32.87, 95%CI 7.91–136.45).

The predictors of skilled delivery services utilization were respondents and spouse educational status. Respondents with secondary education were four times more likely to use skilled delivery services (OR = 3.68, 95%CI1.18–11.46). Similarly, those with post-secondary education were ten times more likely to use skilled delivery services than those who had no formal education (OR = 9.62, 95%CI 2.69–34.42). (Table 7)

The multivariate analysis identified women’s education as significant and independent predictor for the use of child health care services. Using ‘no formal education’ as a reference category, respondents with secondary education were seven times more likely to utilized immunization services (OR = 6.57, 95%CI 1.03–41.56) than those who had no formal education (Table 8).

Read Ending preventable maternal and child deaths in western Nigeria: Do women utilize the lifelines? Part 2

No portion of this research should be used either in digital or printed formats without the express permission of the Researcher. Dr Olaitan Titi @femiolaitan1@gmail.com

Leave a Comment

Your email address will not be published. Required fields are marked *

× How can I help you?