CHAPTER ONE
Introduction
Background to the Study
The health of the mother determines to a large extent the health of her family. Ratzan, Filerman and Lesar (2000) noted that mothers are primary producers of health for their children. Park (2006) stated that a healthy mother brings forth a healthy baby with better chances of survival. United States Agency for International Development-USAID (2008) affirmed that a mother’s health profoundly affects the health and well being of her children. Davour, and Davour (2005) asserted that women’s ill-health impacts seriously on children and families, national productivity and household income and human life. They added that in children and family, women’s ill health can initiate a cycle of ill-health in the next generation.
World Health Organization – WHO (1980) pointed out that with growing recognition of the importance of the health of women in the development process, it has become increasingly obvious that the high mortality of women in developing countries in their middle years is a cause for grave concern. WHO (1998) noted that pregnancy and childbirth are special events in women’s lives and in the lives of their families, and that this can be a time of great hope and joyful anticipation. The WHO further stated that it can also be a time of fear, suffering and even death. Public Health Programme – PHP (2004) added that maternal mortality not only affects the family involved but it also has a great effect on the society as a whole.
Policy Project, Nigeria – PPN (2002) reported that Nigeria contributes ten per cent of the world’s maternal deaths with an average of seven for every 1, 000 births. They added that this indicator has a negative impact on child survival since children who lose their mothers experience an increased risk of death or other complications such as malnutrition. The tragedy is that these women die not from diseases but during the normal life enhancing process of procreation. Park (2006) declared that most maternal deaths are preventable. Lucas and Gilles (2006) pointed out that technologies for prevention of these deaths are available. The challenge, they added, is to achieve universal health care coverage.Childinfo.org (2007) stated that vast disparities persist in maternal health coverage between the industrialized and developing countries, rich and poor, urban and rural, educated and uneducated. They added that all women should have access to basic maternity care through a continuum of services offering quality antenatal care, clean and safe delivery and post partum care for mother and infant with a functioning referral system linking the whole. Child info.org further stated that the simple most critical intervention for safe motherhood is to ensure that women receive care during delivery by skilled health personnel-a doctor, nurse and midwife with the necessary skills to handle normal deliveries safely, to recognize the onset of complications beyond their capacity and to refer the mother for emergency care as needed. WHO (2007a) asserted that in developing countries, interventions that are known to be effective in lowering maternal and prenatal mortality and morbidity are not universally provided. The WHO added that these interventions can be delivered by skilled personnel, providing care during pregnancy, childbirth and postnatal period.
Ezedum (2007) noted that the high maternal mortality ratio in Nigeria is suggestive of a not-so-functional maternal health service. He added that maternal health, an aspect of Maternal and Child Health (MCH) is part of reproductive health. WHO (2007b) defined maternal health as the health of women during pregnancy, childbirth and postpartum period. Delivery of maternal health services is through the health care.
Health care has been defined by William (2003) as the prevention, treatment and management of illness and preservation of mental well-being through the services offered by the medical, nursing and allied health professions. He added that a health care provider or health professional is an organization or person who delivers proper health care in a systematic way professionally to any individual in need of health care services. en.wikipedia.org/wiki/Health_care stated that health care embraces all the goods and services designed to promote health including preventive, curative and palliative interventions whether directed to individuals or to populations. When these goods and services are directed to the health of mothers, it is referred to as maternal health care.
Igwe (1999) defined maternal health care as services rendered by families, communities and health professionals to an expectant woman during the period between conception and birth so that her health and the health of her foetus can be observed and maintained. He further stated that the aim of maternal health care is to reduce the number of maternal deaths resulting from deliveries and complications of pregnancy, childbirth and puerperium. Alakija (2000) defined maternal and child health care as the promotive, preventive, curative and rehabilitative health care for mothers and children. Onuzulike (2004) described maternal health care as health and health-related care fashioned towards helping mothers to cope successfully with the physical and psychological strains under which they are exposed in the course of fulfilling their roles as wives and mothers. Following from the above, maternal health care is referred to in this study as the promotive, preventive, curative and rehabilitative health care for mothers.
Rundel (2005) defined service as a system provided by a government or official organization for the needs of the public. Health services that are provided for mothers are referred to as maternal health care services (MHCS). The concept of maternal health care services in the context of this study implies the promotive, preventive, curative and rehabilitative services rendered by government or private organizations to women in their fecund period to improve their health outcomes and those of their children.
Maternal health care is a component of MCH. Park (2006) noted that the ultimate objective of MCH is life-long health. The components of MHCS include antenatal care, delivery services and postnatal care (Lucas & Gilles, 2006). Deacon (1985) defined antenatal care as the health supervision of the pregnant mother throughout the gestation period, from inception of pregnancy to the onset of the first stage of labour. Bradley (1990) stated that this care is given through the antenatal clinics organized by a midwife while complicated cases will be detected and referred to a doctor for special advice. Antenatal clinic may be located in a hospital, health centre, mobile clinic and dispensary.
The second component of MHCS is the delivery service. This is otherwise known as intranatal, intrapartum or paturient care. Arkutu (1995) defined intrapartum care as health care provided to the mother at the onset of the first stage of labour, through out the completion of third stage of labour, that is, expulsion of placenta. Lucas and Gilles (2006) asserted that the modern trend is for an increasing proportion of birth to take place in maternity centres, hospitals and similar institutions. They further stated that home delivery may be appropriate provided that the person attending the delivery is suitably trained and equipped and that referral to a higher level of care is available early, in case of complications. In all, the most important issue in childbirth is skilled attendant at every birth, conducting delivery under hygienic condition, prompt recognition of delay and complications and referral of mothers for specialized obstetric services.
The last component of MHCS is postnatal care. Lucas and Gilles (2006) defined postnatal services as the care given to a mother from the time she is delivered of her baby to six weeks after. During this period, the woman recovers from the effects and injuries if any, associated with delivery. Postnatal care services are designed to supervise this process, to detect any abnormalities and to deal with them. In particular, the mother should be protected against hazards such as puerperal infection, to which she is liable at this stage. Lucas and Gilles further stated that postnatal service may be a convenient service through which family planning may be introduced. The introduction of family planning will help reduce the risk of early occurrence of another pregnancy, which may carry with it greater risks to the mother. Bradley (1990) pointed out that so many lives can be saved and complications prevented if care is available for mothers throughout pregnancy, childbirth and child rearing. Every mother should be examined early in her pregnancy to detect any risk to herself or her baby so that she can have the necessary care to prevent serious problems in pregnancy and childbirth.
Park (2006) declared that health care is a public right and it is the responsibility of government to provide this care to all people in equal measure. The Nigeria’s National Health Policy – NHP (1988) has a goal of attaining a level of health that will enable all Nigerians achieve socially and economically productive lives with a national health system based on Primary Health Care (PHC). William (2003) noted that health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play.
Regrettably, Oyediran (2006) lamented that the non-government health sector in Nigeria currently lacks any co-ordination or standardization of service delivery thereby reducing its collective efficiency as an alternative to the public health delivery system. Adegoroye (2003) observed that health care is labour and capital intensive and provides relatively paltry returns compared with other sectors, which discourage private investment. In this study, private health facilities refer to those health facilities owned by individuals and are duly registered with the local government council with a medical practitioner coordinating its affairs. MCH Policy (1994) indicates that the provision of maternal and child health services is the responsibility of all levels of government.
Provision has been defined by Hornby (2001) as the act of supplying somebody with something that they need or want. Provision in the context of this study is to give women in their fecund period adequate MHCS they need to improve their health outcomes and those of their children. Frey (1977) believed that the efficiency with which public goods and services are provided depends on the level of government that is responsible for its provision especially in a multi-level government. Nigeria operates the federal system of government whereby there is government at the centre and at the subnational levels, that is, state and local governments.
Omeje (2000) noted that management and infrastructural provision for health in the public sector is on a tripartite formula shared among the three tiers of government – federal, state and local government. PHC facilities which are the responsibility of the local government are supposed to provide basic preventive and health promotion services that include immunization, health education, and promotion of adequate nutrition as well as management of simple malaria, diarrhoea, acute respiratory infections (ARI) and other common illnesses. PHC also provides antenatal care, family planning services and basic surgical services (PPN, 2002).
The primary goal of any health care service is to achieve the highest possible level of well being. This can only be possible if resources are provided for its operation to maximize objectives. Lucas and Gilles (2006) stated that the resources required by the health services include money, manpower, materials and management. MCH policy (1994) stated that finance (money), manpower and equipment or materials are resources needed to translate MCH policy into programmed activities. Oyediran (2006) maintained that the health problems facing Nigeria involve inadequate provision of trained medical and paramedical personnel; and the ineffective utilization by the community of the services provided. Hopkin and Riuz-Tiben (1997) stated that for services provided to be considered effective, the services have to be utilized by the people for whom they have been provided.
Utilization, according Hornby (2001), is to use something especially for a practical purpose. White Hurst and Jaco (1989) defined health facility utilization as the use of health facilities by the target population for whom the facilities are designed. Emmanuel,Elsvan,Dekker, JanGeertzen and Joost (2005) defined use of health services as the process of seeking professional health care and submitting oneself to the application of regular health services with the purpose of addressing health problems. In the context of this study, utilization shall imply the use of existing MHCS for the purpose of improving the quality of lives of women in their fecund period and those of their children.
One way of determining utilization of MHCS was to determine the level of utilization of MHCS by mothers. To do this, Olaitan’s (1983) criterion adapted from Likert’s scaling was adopted. Going by his work, utilization level of equal to or greater than the criterion mean (in this case 1.5) was regarded as effective utilization and utilization level below 1.5 indicated ineffective utilization. Bradley (1990) stated that modern (scientific) health care services are available in the dispensaries, clinics, health centres, mobile clinics, hospitals and maternity homes. She added that good facilities may exist but may be poorly used by a local population. She outlined some reasons for non-utilization of services to include ignorance, illiteracy, fear and the belief that one has to be sick to look for health care. Other reasons according to her were that it is not possible to take a day off work to go and use the services or that there is no transport or that services are not available locally. WHO (1980) observed that excessive burden of work, in women’s lives is seen in many areas as they spend the day in agricultural work, fetching water, in preparing meals and at the market and thus might not have the time or energy to make use of the services. Nweke (2004) enumerated factors influencing the health of mothers as age of mother, educational level of mother, number of deliveries and child-spacing. Other factors according to him, are family size, climate, customs, inherited diseases, social class, and negative attitudes of some fathers to the female child.
en.wikipedia.org/wiki,Maternal_health reported that factors which prevent women in developing countries from getting the health care they need include distance from health services, cost (direct fees as well as the cost of transportation, drugs and supplies), multiple demands on their time and women’s lack of decision-making power within the family. They added that the poor quality of services including poor treatment by health providers also make some women reluctant to use services.
Utilization may be influenced by predisposing factors (demographic and socio-economic characteristics, knowledge and attitude of the potential clients as well as their perceived need for services). Utilization may also be influenced by enabling factors (affordability, availability, accessibility and acceptability). Another factor identified as influencing utilization is the health system factors which include norms, policies, resources and organization within the services (Poole & Carlton, 1986). WHO (2004) also noted that maternal health outcomes are influenced by a range of multisectoral factors including government policies, health system, other sectors such as education and transport, household and community behaviours and cultural norms. All these they added, have the potential of severely restricting or enhancing good maternal health.
Ding (1974) noted that availability of personnel (workers), workers’ attitude towards work and facility users, accessibility of facilities and cost of providing services are factors militating against adequate provision and utilization of public health care facilities. Population Report (1985) indicated that age, parity, educational level and employment had major influence on the utilization of health services. The report noted that there was a high rate amongst women aged 30 to 39 years, and least among women aged below 30 years. The report also indicated that utilization rate was high among women with two to three children, better educated women and among urban women. Some of these factors may influence provision and utilization of MHCS.
Emeke (2000) reported that socio-economic status of a woman influenced utilization of maternal health services. In another vein, Health Promotion International (2001) reported that husband’s occupation can be considered a proxy of income as well as social status. They noted that women whose husbands worked in business or services were more likely to be users of modern health care service to treat complications during pregnancy.
Age of mother has been identified by Al-Nahedh (1995) as having an association with MHCS use. Health Promotion International (2001) and Okoro (2006) made similar observations.
The influence of parity on MHCS has been indicated by Navaneethan and Dharmalingam (2000). Similar association was reported by (Health Promotion International, 2001; Sarma & Rempel, 2003 & Agbaje, 2006).
Maternal education has been identified as an important factor in MHCS utilization. Studies by Ejima (1998); Health Promotion International (2001); Sarma and Rempel (2003); and Vogl (2004) have shown that maternal education exerts a positive influence on the probability that a woman seeks prenatal or delivery care.
Mother’s occupation is another important factor, which may be associated with MHCS utilization. Studies by Cesar and Walker (1980); Navaneethan and Dharmalingam (2000); Health Promotion International (2001); and Simore (2005) have demonstrated such association.
The above reports underpin the implication of these factors as variables for the present study. Similarly, factors that influence provision (especially in rural areas such as Emohua) such as policy factors; health system factors – availability of personnel, essential supplies, costs, (official and unofficial charges); road and transportation may be studied (Srinivassan and Sugathan, 1976; Al-Nahedh, 1995; Hutton, 2002; Nanda, 2002; Baltussen, Hadad and Saurborn, 2002; Khalid, 2004 & Gage, 2006).
Emohua LGA is a local government area in the main land parts of Rivers State surrounded by massive area of land and vegetation favourable for cultivation. It is a rural and predominantly a farming community. Some health-related harmful cultural practices such as early marriages with its attendant health risks, female genital mutilation, desire for many children, male child preference, use of unhygienic objects for cord cutting, daily scalding hot baths after delivery may still be observed in the area. These practices may have negative health consequences on the baby as well as the mother ranging from obstructed labour to infections and others. The LGA has two general hospitals, one cottage hospital, thirteen health centres, one infant welfare clinic and four private clinics as well as traditional birth attendants and spiritual healing homes. (Health Department, Emohua Local Government Council, 2008).
However, WHO (2007c) stated that, the physical existence of health facilities does not mean that they function. The WHO further stated that most of them are poorly equipped and lack essential supplies and qualified staff. The WHO also added that the performance of the Nigeria health system is worse than any Sub-Sahara countries. Madunagu and Olaniran (2005) stated that available data have shown that the availability and accessibility to quality health care services in Nigeria is poor. Oyediran (2006) observed that in Nigeria, the MCH services available provide care only to a small percentage of the population, who are mainly those living in the urban area. He further stated that over 85 per cent of the population live in rural areas where medical facilities and coverage are lacking. The situation in Emohua LGA may not be different from the general picture presented here. The urban bias of service provision, coupled with widespread lack of equipment and timely supplies at the health centres in the rural areas may have grave consequences during obstetric emergencies.
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