British Journal of Education, Society & Behavioural Science 12(2): 1-9, 2016, Article no.BJESBS.18208 ISSN: 2278-0998

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Determinants of the Level of Utilization of Maternal Health Care Services ‘Abiye Programme’ by Rural Women in ,

O. O. Fasina 1, F. I. Wole-Alo 1* and F. L. Idowu 1

1Department of Agricultural Extension and Communication Technology, Federal University of Technology, , Ondo State, Nigeria.

Authors’ contributions

This work was carried out in collaboration between all authors. Authors OOF and FIWA designed the study, wrote the protocol and supervised the work. Authors OOF and FLI carried out all laboratories work and performed the statistical analysis. Author OOF managed the analyses of the study. Author FLI wrote the first draft of the manuscript. Author FIWA managed the literature searches and edited the manuscript. All authors read and approved the final manuscript.

Article Information

DOI: 10.9734/BJESBS/2016/18208 Editor(s): (1) Manouchehr (Mitch) Mokhtari, School of Public Health, University of Maryland, College Park, USA. (2) Tyree Oredein, Health Education & Behavioral Sciences, University of Medicine and Dentistry of New Jersey, USA. (3) Madine VanderPlaat, Department of Sociology and Criminology, Saint Mary's University, Canada. (4) Chan Shen, Department of Biostatistics, University of Texas, USA. Reviewers: (1) Ryan michael f. Oducado, West Visayas State University, Philippines. (2) Anonymous, University of Malaya, Malaysia. (3) Anonymous, The American University in Cairo, Egypt. Complete Peer review History: http://sciencedomain.org/review-history/11604

Received 9th April 2015 Accepted 2nd September 2015 Original Research Article th Published 28 September 2015

ABSTRACT

This study examined factors affecting the utilization of maternal health care services ‘Abiye programme’ by rural women of Ondo State, Nigeria. A multistage and purposive sampling technique was used to select one hundred and twenty women for the study. Descriptive statistics such as frequency tables, percentages and means were used to present study findings. Pearson Product Moment of Correlation (PPMC) was used to test the study hypothesis where p<.05 determined significance. Data revealed that the majority (75.0%) of the rural women were married, with mean age of 30 years, and 20.8% had adult education. Services most utilized by respondents

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*Corresponding author: E-mail: [email protected];

Fasina et al.; BJESBS, 12(2): 1-9, 2016; Article no.BJESBS.18208

included provision of free drugs (98.0%), free medical care for children less than five years (95.8%) and free delivery i.e. the process of birthing (95.0%). PPMC revealed that ages of the respondent (r = 0.210; p ≤ 0.05) and household size (r = -0.221; p ≤0.05) were significant determinants of the level of utilization of maternal health services ‘Abiye programme’. Two major constraints faced by the respondents’ were lack of income-generating activities, and distance to the maternity centers. The study concluded that the maternal health care services were highly utilized. It is recommended that free medical care for children less than five years of age, and free medications for pregnant women should continue irrespective of the change in government.

Keywords: Maternal health; abiye programme; utilization and rural women.

1. INTRODUCTION infant maternal health record [2]. Globally, Nigeria accounts for about 10% of all maternal Motherhood is often associated with ill-health deaths, and has the second highest mortality and death in developing countries, and Nigeria in rate in the world, after India. Thus, for every particular. The World Health Organization has woman that dies from pregnancy-related causes, defined maternal mortality as “the death of a 20 to 30 more will develop short- and long-term woman while pregnant or within 42 days of a damage to their reproductive organs resulting in termination of a pregnancy, irrespective of the disabilities such as obstetric fistula, pelvic duration and site of the pregnancy, from any inflammatory disease and a ruptured uterus [6]. cause related to or aggravated by the pregnancy Maternal mortality is higher in women living in or its management but not from accidental and rural areas and among poorer communities. incidental causes” [1]. The maternal mortality Between 1990 and 2013, maternal mortality ratio is the number of women who die during dropped by almost 50% [5] pregnancy and childbirth, per 100,000 live births [2]. In 2013, the maternal mortality ratio in These high morbidity and mortality rates from developing countries was 230 per 100 000 live maternal health informed the decision of the births compared to 16 per 100 000 live births in Ondo state government to implement a maternal developed countries. According to the United health care programme ‘Abiye’ in local Nations (UN) [3] Nigeria ranks high regarding government area. The mission of the ‘Abiye’ maternal and infant mortality rates with a ratio of programme is to bring qualitative and effective 545-630 per 100,000 live births on the maternal health care services to people where they live, mortality index and 75 per 1,000 live births on work and play. The objective is to strategically the infant mortality index, this makes the country counter the four phases of delay, reach out to the the second largest contributor to the under–five targeted people and remove all barriers in and maternal mortality rate in the world [4]. There achieving safe motherhood in Ondo state. The are also large disparities within countries such as four phases of delay include: delay on the part of Nigeria between women with high and low the patients to seek care when complications income and between women living in rural and arises, delay in reaching care due to poor urban areas [5]. infrastructural support, communication challenges and transport, Delay in accessing The high rate of women and infants dying during care due to poor facilities, delay in referral care child delivery informed world leaders meeting at for “at risk cases” or emergencies [7]. the United Nations Millennium summit in 2000 which adopted seven Millennium development 1.1 Objectives of the Study goals. While infant mortality was christened Millennium Development Goals (MDG-4), maternal mortality was dubbed Millennium The objective of the study was thus to determine Development Goals (MDG-5) with the aim of the factors influencing the utilization of maternal achieving 75 per cent drop from the level of health care facilities provided by the programme maternal mortality in 2015. It was on this in Ifedore Local Government Area of Ondo State, backdrop that the World Health Organization Nigeria. Specifically, the study; (WHO), the United Nations Children’s Fund (UNICEF) and other multilateral donor agencies i. described the socioeconomic released funds to many developing nations, characteristics of respondents in the study including Nigeria, to enable them to improve their area;

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ii. determined the level of utilization of respondents such as age, sex, religion, marital maternal health care facilities by status, educational level, farming experience, respondents and farm size and membership of social organization. iii. identified the constraints affecting the Thus were measured as follow: respondents’ utilization of the maternal health care services. Age; was measured by asking the respondent to state their actual age in years, this was 2. METHODOLOGY measured at nominal level.

The study was purposively carried out in Ifedore Religion; was measured at nominal level and Local Government Area in Ondo–State because labelled as Christianity=1, Islamic=2, traditional it was the first location for the programme religion=3 implementation. Ifedore Local Government Headquarters is in Igbara-Oke. Igbara-Oke has Marital status; was measured at nominal level an area of 295 km square and a population of and labelled single =1, married=2, divorced=3, 176,327 [8] Ifedore local government area lies Widowed=4, separated=5. within the latitude 7° 24' 0" North and longitude 5° 3' 0" East. It has nine communities which Highest Educational Level; acquisition of any include Igbara-Oke, Isarun, Ero, Irese, Ikota, formal education by the respondents was , , Ibule and Ilara. The people of measured as either yes or no (yes-2, no-1). Ifedore Local Government Area are While educational level of the respondents was predominantly Yoruba; there is co-existence of measured in years of formal education as various dialects of the . They Completed tertiary school-16, attended tertiary are mostly farmers and traders. school-14, completed secondary-12, attended secondary school-10, completed primary school- 2.1 Sample Size and Sampling Technique 6 and attended primary school-2.

A multi-stage sampling technique was used for Farming Experience; respondents stated actual this study. At the first stage, purposive sampling years of farming experience were measured at technique was used to select two communities interval level. (Igbara-Oke and Ijare) based on the presence of maternity centres while two communities (Ilara Farm size; respondents stated actual farm size in and Ibule) were selected based on the non- hectares was measured at interval level. presence of maternity centres. Purposive sampling was employed at the second stage to Family size/household size; actual number of select 30 women within the reproductive age of people in their family was measured at interval 15-49 years from each community. A total of 120 level. respondents were interviewed for the purpose of this study. Constraints of users of maternal health services were measured on a four point rating scale to 2.2 Measurement of Variables determine the level at which they affect the respondents. Thus: ‘Always a problem’ was 2.2.1 Dependent variables given =1, ‘Sometimes a problem’ =2, ‘Never a problem’ =3, ‘Never Affected=4. The dependent variable of the study is the level of utilization of maternal health care facilities by 3. RESULTS rural women. Level of utilisation of maternal health care services by the respondent was 3.1 Socio-Economic Characteristics of measured at the interval level by adding up all Respondents the services utilized per respondent. This was then ordered into low, moderate and high level Table1 indicates that the majorities (75%) of the categories of utilization. rural women were married, 15.8% were single, 3.3% were divorced, and 5.9% were living 2.2.2 Independent variables separately from their husbands. Table 1 shows that 60% of the rural women were Christians, The independent variables of the study included 35.8% were Muslims and 4.2% practiced the socio economic characteristics of the traditional religion. Table 1 also revealed that the

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majority of the women were between 31-40 years Table 1. Distribution of respondents (42.5%), 39.1% where between 21-30 and according to their socio-economic 12.4% were under 20 years of age, while those characteristics between ages 41-50 years constituted 5.9% of the women. The mean age is 29±7 years. Table Characteristics Frequency Percentage 1 also revealed that more than 40% of n=120 respondents had less than a primary education, Marital status where almost 16% had no formal education at Single 19 15.8 all. Only 6.8% of respondent completed tertiary Married 90 75.0 education. Table 1 also reveals the distribution of Divorced 4 3.3 respondents according to household size. Mean Separated 7 5.9 household size was 7 persons with majority Religion (46%) having household sizes within the range of Christianity 72 60.0 6-10 persons while those below 5 persons were Islamic 43 35.8 21.6%. Those between the ranges of 11-15 Traditional 5 4.2 persons were 19.2% and the minority had religion household sizes of 16 and above (12.5%). The House hold size (persons) table indicated that women that had less than Below 5 26 21.6 three children were 19.2%, respondents with 7 to 6-10 56 46.7 10 children were 33.3% while respondents 11-15 23 19.2 having between 3-6 had highest percentage of 16 and above 15 12.5 42.5%. The mean number of children was 3. Age Below 20 15 12.4 3.2 Services Utilized in the Maternal 21-30 47 39.1 Health Care ‘Abiye’ Programme 31-40 51 42.5 41-50 7 5.9 Fig. 1 shows the distribution of services utilized Educational level under the maternal health care ‘Abiye’ No formal 19 15.8 programme in the study area. Provision of free education drugs was the service mostly utilized by the Adult education 24 20.0 respondents (98.8%). This was followed by free Complete primary 24 20.0 medical care for less than five year old children school (95.8%), free child delivery i.e. no payment for Incomplete 7 5.8 medical attention received during child delivery primary school (95.0%), check-up during pregnancy (93.3%), Complete 14 11.6 visit by health rangers (90.8%), checkup after secondary school pregnancy (75.0%), free operation (66.7%,), use Incomplete 24 20.0 of phone services (65.8%) and lastly the use of secondary school ambulance (60.8%). Complete tertiary 8 6.8 Source: field survey 2013 3.3 Level of Utilization of Maternal Health Services The test of the relationship between respondents’ socio-economic characteristics and According to Table 2 majority of the respondents their level of utilization of maternal health (86.7%) fell into the high level of utilization services by the respondents was determined category, followed by 13% who fell in the using Pearson Product Moment Correlation. The moderate utilization category while less than 1% result presented in Table 3 indicates that none of of the respondents fell into the low utilization the characteristics were significant except age category. and farm sizes of the respondents. Analysis indicates a significant negative correlation 3.4 Test of Hypothesis between the ages of the respondents and their level of utilization of maternal services (r = - Ho 1 = There is no significant relationship 0.210, p ≤ 0.05). This implies that the younger between the socioeconomic characteristics the respondents the greater they utilized the of the respondent and their level of maternal health services. This may be because utilization of maternal health care services the older respondents are more traditionally in the study area. bound to traditional ways of giving birth than the

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younger respondents who may be more generating activities, approximately 29.5% were enlightened and prone to innovativeness. Total once affected while only 27.5% were never farm size also has significant relationship with affected (mean score is 2.7). Table 4 shows that the level of utilization of maternal services, this the 45.8% of women were usually affected by the result implies that respondents with large farm distance to the maternity center. 30.8% was size may not have time to attend clinic to receive once affected by distances while 23.3% were maternal services due to the volume of work they never affected. Table 4 reveals that majority may have to contend with. (41.7%) were usually affected by lack of transportation, 31.7% were once affected while Table 2. Level of utilization of maternal health 26.7% were not affected. services Table 4 further shows that (37.5%) of the No of services utilized F % majority were never affected by poor network to 1-3 (low) 1 0.8 call the health rangers, (30.8%) were once 4-6 (moderate) 15 12.5 affected while (31.7%) were always affected and 7-9 (high) 104 86.7 the mean score is 2.4. Total 120 100.0 Table 4 also shows that 35 .8% which are the 3.5 Constraints Faced by the majority of the respondents were never affected Respondents in Utilization of Services by waiting for so long at the maternity, 35.8% of ‘Abiye’ Programme were once affected while 28.3% were always affected, and the mean score is 2.4. Table 4 Constraints faced by respondents with regards to reveals that 59.2% of the majority of the the utilization of the services of the maternal respondents was never affected by lack of health services programme are presented in information concerning the Abiye Programme, Table 4. The table reveals that the majority of 19.1% were once affected and 21.7% were women (46.7%) were always affected by income always affected.

120

98.3 95 95.8 100 90.8 93.3

80 75 66.7 65.8 60.8 60

40

20

0

Fig. 1. Distribution of respondents according to services of ‘Abiye’ programme utilized Source: field survey 2013

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Table 3. Results of Pearson product moment correlation between the respondent’s socio economic characteristics and their level of utilization of maternal health services

Age Household Number of Years of Total Level of size children experience farm utilization size Age 1 Household R-value 0.165 1 size p-value 0.072 Number of R-value 0.673** 0.406** 1 children p-value 0.000 0.000 Years of R-value -0.033 0.066 0.064 1 experience p-value 0.724 0.474 0.486 Total farm R-value 0.100 0.082 0.107 0.568** 1 size p-value 0.276 0.374 0.245 0.000 Level of R-value -0.210* -0.103 -0.066 -0.041 -0.221* 1 utilization p-value 0.021 0.267 0.476 0.655 0.015 Source: field Survey 2013

Table 4. Distribution of respondents according to constraints faced on the utilization of Abiye programme services

Constraints faced by the respondents Not Once Always Mean affected affected affected F (%) F (%) F (%) 1 Long waiting at the maternity centre 43 (35.8) 43 (35.8) 34 (28.3) 2.4 2 Lack of transportation 32 (26.7) 38 (31.) 50 (41.7) 2.7 3 Lack of professionals at the maternity center 96 (800.0) 9 (7.5) 15 (12.5) 1.4 4 Insufficient health care facilities at the centre 79 (65.8) 27 (22.5) 14 (11.7) 1.6 5 Poor network to call the health rangers 45 (37.5) 37 (30.8) 38 (31.7) 2.4 6 Distance to maternity centre 28 (23.3) 37 (30.8) 55 (45.8) 2.8 7 Income generating activities/occupation 33 (27.5) 31 (29.5) 56 (46.7) 2.7 involved in 8 Religious beliefs 78 (65.0) 22 (18.3) 20 (16.7) 1.6 9 Lack of information concerning the Abiye 71 (59.2) 23 (19.1) 26 (21.7) 1.9 Programme

Table 4 also reveals that 65.0% of the majority Onasoga et al . [9] found in their study where the were never affected by religious belief, 18.3% majority of the respondents (93.7%;) were were once affected, 16.7% were always affected married and 4 (6.3%) were single respondents. (mean score is 1.6). Table 4 shows that the The high proportion of the married women is majority (65.8%) was never affected by highly correlated with their mean age, equally in insufficient health care facilities at the center Ondo State Nigeria great importance is attached while 22.5% of the respondents were once to marriage as married women are highly affected and 11.7% were always affected. Lastly respected. the Table reveals that majority (80.0%) was never affected by lack of professionals at the Similarly, Akanbiemu et al. [10] found the maternity center, 7.5% of the respondents were majority (89.3%) of the respondents were once affected and 12.5% always affected while presently married. While the majority of women their mean score is 1.4. were Christian 60%, 35.8% of the women were Muslim and there were some women who 4. DISCUSSION practiced traditional religion (4.2%). Thus, it is likely that religion does not have a major effect Married women constitutes a larger percentage on the level of utilization of maternal health care of the respondents (75%), 15.8% were single, service. Mean household size was 7 persons 3.3% were divorced, 5.9% were living separately with majority (46%) having household sizes from their husbands. This corroborates what within the range of 6-10 persons while those

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below 5 persons were 21.6%. Those between Approximately 46.7% of the women were always the ranges of 11-15 persons were 19.2% and the affected by income generating activities which minority had household sizes of 16 and above hinders the utilization of maternal health (12.5%). The table indicated that women that services. Since the major occupation in rural had less than three children were 19.2%, areas is farming, most of the respondents respondents with 7 to 10 children were 33.3% suffered from the low-income productivity, 29.5% while respondents having between 3-6 had were once affected while only 27.5% were never highest percentage of 42.5%. The mean number affected (mean score is 2.7). The study shows in of children was 3. Table 4 that the 45.8% of women were usually affected by the distance to the maternity center. The study found out that the majority of the 30.8% was once affected by distances while women were between 31-40 years (42.5%), this 23.3% were never affected; this is in agreement age category represented the active production with Ebere [14]. Table 4 reveals that majority stage of farmers. Hence the result corroborated (41.7%) were usually affected by lack of Akubuilo [11] who reported that the age the rural transportation, 31.7% were once affected while women in Enugu agricultural zone of Enugu 26.7% were not affected. State spread across the various age categories with significant proportion of them above 35 Majority of the respondents were never affected years of age. 39.1% of the respondents were by poor network to call the health rangers, between 21-30 while 12.4% were under 20 years (30.8%) were once affected while (31.7%) were of age and those between ages 41-50 years always affected and the mean score is 2.4 which constituted 5.9% of the women. The mean age is shows that there is stability of network though it 29±7 years. This mirrors Akanbiemu et al. [10]) is a rural area. Table 4 also shows that 35 .8% who found the mean age of respondents in his which are the majority of the respondents were study to be 29.8±7.3. This study found that more never affected by waiting for so long at the than 40% of respondents had less than a primary maternity before nurses attended to them, this education of these almost 16% had no formal shows that the nurses at the maternity Centre education at all this is in line with Acha [12] who are competent in attending to the respondents, found that 40.1% of the women had no education 35.8% were once affected while 28.3% this may while 17.8% had primary school education . Only happened due to the fact that the nurses might 6.8% of respondent completed tertiary education, be waiting for other women to come before women with no formal education might have little starting the regular meetings, and the mean knowledge about maternal health services; this is score is 2.4. The result also shows that 59.2% of consistent with the findings of Addai [13]. the majority of the respondents was never affected by lack of information concerning the According to Fig. 1, provision of free drugs was Abiye Programme this implies that the health the service mostly utilized by the respondents rangers visit the respondents often by informing (98.8%), this was closely followed by free them of the latest information concerning Abiye medical care for less than five year old children Programme while only 19.1% were once affected (95.8%). Free child delivery (95.0%) i.e. the and 21.7% were always affected. process of birthing (natural) where pregnant women do not pay for the services utilized, The respondents were not restricted by their check-up during pregnancy (93.3%) i.e. religious beliefs in utilizing the maternal health antenatal, visit by health rangers (90.8%), care services this is because 65.0% of them checkup after pregnancy (75.0%), free operation made use of the Programme, 18.3% were once (66.7%,), use of phone services (65.8%) and affected, 16.7% were always affected (mean lastly the use of ambulance (60.8%). score is 1.6). Table 4 shows that the majority (65.8%) was never affected by insufficient health Many of the respondents fell into the high level of care facilities at the center while 22.5% of the utilization category (86.7%) where they utilized respondents were once affected and 11.7% were between seven and nine of the services available always affected; this implies that there are in the study area of which 13% fell in the sufficient health care facilities provided by the moderate utilization category showing usage of government at each maternity center of the four to six services. Those respondents that locale. Finally, Table reveals that majority made use of one to three services fell into the (80.0%) was never affected by lack of low utilization category this can be seen in professionals at the maternity center, 7.5% of the Table 2. respondents were once affected and 12.5%

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always affected while their mean score is 1.4 REFERENCES indicating they never affected this is because there are skilled birth attendants at every 1. Bullough CHW. Analysis of maternal maternity centre of the study area. deaths in the central region of Malawi. East African Medical Journal. 5. CONCLUSION AND RECOMMENDA- 1981;58(1):25-36. TION 2. Okwara Vanessa. Why reduction of maternal mortality rate by 2015 is not The study concluded that the respondents highly achievable; 2013. utilized the ‘Abiye’ maternal health care services. Available:http://nationalmirroronline.net/ne Major constraints to the utilization of maternal w/why-reduction-of-maternal-mortality- health care services included lack of rate-by-2015 is-not- achievable-expert rd transportation and influence of their income (Accesssed on 23 January, 2014) generating activities. Age and farm size of the 3. United Nations (UN). World Population respondents were the only socioeconomic Prospects and the Institute for Health characteristics that significantly affected their Metric Reports of 2010 published in 2012. level of utilization of the ‘Abiye’ maternal 4. United Nations International Children's healthcare service programme in Ifedore LGA of Emergency Fund (UNICEF), 2015: United Ondo State. Based on the findings from this Nations Development Assistance study, several issues to be taken into account to Framework for 2014-2017. improve quality of services in their facilities are 5. World Health Organization (2007), highlighted below: Maternal Mortality in 2013: WHO fact sheet on Maternal Mortality with key facts 1. Maternal health education should be and providing information on MDG4, where intensified to educate rural women on the death occurs, causes, lack of care and importance of utilizing maternal health care WHO response. services. Available:http://www.who.int/mediacentre/f 2. Government should create programmes actsheets/fs348/en (Accessed: November that can help to boost income of rural 26, 2014) women 6. Ogunjuyigbe PO, Liasu A. The social and 3. Government should endeavor to equip the economic determinants of maternal maternity centers with more facilities and morbidity and mortality in Nigeria; 2007. there should be a continuity of this Available:http://uaps2007.princeton.edu/do programme called “Abiye” safe wnload.aspx?submissionId=70155 motherhood. They should also ensure free (Accessed: December 1, 2014) accessibility to these facilities. 7. Fajimbola Tunde. ‘Abiye’ safe motherhood: 4. There is a need to intensify awareness on A case of leadership in turning tide of this programme and this could be achieved maternal mortality in Nigeria in Nigerian through awareness campaigns, health journal.com; 2011. enlightenment programs by effective 8. Report of Nigeria's National Population participation of government, NGOs, local Commission on the 2006 Census. leaders and mass media so that other local Population and Development Review. government areas can also benefit from it. 2007;33(1):206-210 5. Education and sensitization should be 9. Onasoga AO, Osaji TA, Alade OA, extended to husbands of pregnant women. Egbuniwe MC. Awareness and barriers to They should be counseled to relieve or Utilization of Maternal Health care services assist their wives in their income among reproductive women in Amassoma generating activities so that they can find community, Bayelsa State; 2014. time to attend and utilize the service’s 10. Akanbiemu FA, Manuwa-Olumide A, provided by the ‘Abiye’ programme. Fagbamigbe AF, Adebowale AS. Effect of perception and free maternal health services on antenatal care facilities COMPETING INTERESTS utilization in selected rural and semi-urban communities of Ondo State, Nigeria. Authors have declared that no competing British Journal of Medicine & Medical interests exist. Research. 2013;3(3):681-697 .

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11. Akubuilo CJC. Poverty alleviation in 13. Addai I, Determinants of use of maternal- agriculture study of rural women farmers in child health services in rural Ghana. Enugu agricultural zone of Enugu State, Journal of Biosocial Science. 2000;32(1): Nigeria. Journal of Science. 2002;2(1):50- 1-15. 55. 14. Ebere ZO. (2013): A review of the barriers 12. Acha CK. Trend and levels of women and socio-cultural factors influencing the empowerment in Nigeria. American access to maternal health care services in Journal of Applied Mathematics and Nigeria. National population commission of Statistics. 2014;2(6):402-408. Nigeria (web); 2006. ______© 2016 Fasina et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Peer-review history: The peer review history for this paper can be accessed here: http://sciencedomain.org/review-history/11604

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