Elsevier

Social Science & Medicine

Volume 63, Issue 7, October 2006, Pages 1870-1878
Social Science & Medicine

Factors associated with the use of maternity services in Enugu, southeastern Nigeria

https://doi.org/10.1016/j.socscimed.2006.04.019Get rights and content

Abstract

The maternal mortality ratio and other maternal health indicators are worse for developing countries than for the developed world due to improved access to quality care during pregnancy and especially at delivery in the industrialized world. This study was carried out to identify the factors which influenced choice of place of delivery by pregnant women in Enugu, southeastern Nigeria, and to recommend ways to improve women's access to skilled attendants at delivery. A pre-tested questionnaire was administered by interviewers to women who had delivered within 3 months prior to date of data collection. The response rate was 75.5% (n=1098). Of the respondents, 52.9% delivered outside health institutions and 47.1% in health institutions. The major factors influencing choice of place of delivery included promptness of care, competence of midwife/doctor, affordability, health education, 24 h presence of doctors, team work among doctors and presence of specialist obstetricians. There were statistically significant associations between choice of institutional or non-institutional deliveries and socio-demographic/economic factors such as place of residence (urban/rural), religion, educational status, tribe, marital status, occupational level, husband's occupational and educational levels, age and parity (p<0.05).

We conclude that factors which will positively influence women to deliver in health institutions in Enugu, Nigeria include a variety of interacting social, economic and health system factors, which operate at various levels—the household, community, the health institutions and the larger social and political environment. Attention to these factors will not only improve maternity utilization but, hopefully, also will reduce the high maternal mortality and improve other maternal health indicators in the study area.

Introduction

The Safe Motherhood Initiative (SMI) was launched in Nairobi, Kenya in 1987 with the goal of reducing maternal mortality globally by half by the year 2000. Available data have shown that the maternal mortality ratios and other maternal health indicators (e.g. percentage antenatal care, percentage deliveries in health facilities and percentage skilled attendance at delivery) in most developing countries have worsened instead of improving since the launching of the SMI. In Nigeria, e.g., a study which compared MMRs in a particular institution before and after the launching of the SMI showed a 600% increase after the launching of the SMI compared to before (Okaro et al., 2001). Two very recent studies, which covered six of the 36 states of Nigeria also showed current high maternal mortality ratios in various parts of Nigeria (Fatusi, 2004; SOGON, 2004).

Many reasons have been adduced for this worsening situation of maternal health indicators in Nigeria and range from socio-economic factors through poor infrastructural facilities to poorly organized health systems (Madunagu et al., 2004). Shortly after the launching of the SMI, it was hoped that effective antenatal care would reduce the MMRs in developing countries (Harrison, 1990). However, it became apparent that many women who faithfully attended antenatal clinics ended up delivering in less than ideal places. Those who developed complications were then transferred to hospitals as emergencies. With the realization of the limitations of antenatal care in predicting obstetric emergencies and therefore in reducing maternal mortality ratios, emphasis later shifted to emergency obstetric care (EmOC) as the short-term solution to the high maternal mortality ratio in developing countries. Despite all these measures, the MMRs and other maternal health indicators in Nigeria have remained appalling.

The organization of health services in Nigeria is such that there is no proper referral system between the primary, secondary and tertiary levels of care (Chukudebelu, 1995). Maternal health care needs to be a linked system operating at different levels and at different points in the reproductive cycle (Royston & Armstrong, 1989). The maternity care situation in Nigeria is such that tertiary care centres take on low risk obstetric cases while primary health centres take on high risk cases which should appropriately be handled by tertiary centres. In other words, in the absence of a proper referral system, parturients who utilize obstetric services deliver in facilities where they should not vis-à-vis their risk status.

Thus in the absence of a reliable referral system, one improperly understood issue is what determines where a pregnant Nigerian woman delivers. If the factors which guide the decisions on where they deliver are known, these will help in the more efficient organization of maternity services in Nigeria so that both the perceived and actual quality of obstetric care will improve and thereby encourage more women to seek and use available obstetric services. Based on the above, this study had the following objectives:

  • (1)

    To identify the factors which influence the choice of place of delivery by pregnant women in Enugu, South Eastern Nigeria.

  • (2)

    To make recommendations on ways to improve women's access to skilled attendants at delivery in this community.

Section snippets

Study area

This was a population based cross-sectional survey carried out in Enugu, capital of Enugu State in southeast geopolitical zone of Nigeria. Enugu State has 17 local government administrative areas. The Enugu capital city (where this study was based) has a population of 464,514 inhabitants (National Population Commission, Enugu, Nigeria, 1996 projection). It is spread over an area of 611,590 km2 (Survey Department, Ministry of Works and Housing, Enugu, Nigeria, 1999). It has a hilly topography. It

General characteristics of the study subjects

Out of a total of 1450 women to whom the questionnaire was administered, 1095 women responded giving a response rate of 75.5%. The mean age of the women was 27.8±11.8 (range: 15–43) yr. The mean parity was 3.1±2.3 (range: 0–11). Of them 450 (41.1%) lived in the urban parts of the study area while the remaining 645 (58.9%) lived in the rural parts. Of the respondents 822 (80.5%) were Ibos, 161 (14.7%) were Hausas, while the remaining 52 (4.7%) were Yorubas; 620 (56.6%) were Christians of various

Discussion

The study of utilization patterns for maternity services is an important step in more fully understanding the mechanisms responsible for the observed discrepancy in pregnancy outcomes between the developed and developing countries. This study has confirmed that even where maternity care services are reasonably available as in the study areas, the percentage delivery in health facilities was still low (Table 3). While this is in agreement with studies of other Nigerian populations (Akpala, 1998;

Acknowledgements

The authors are grateful to the consultant, resident and nursing staff of the University of Nigeria Teaching Hospital, Enugu, Nigeria for assisting with the various aspects of this study.

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