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