COMPARATIVE ASSESSMENT OF UTILISATION OF MATERNAL AND
CHILD HEALTHCARE SERVICES IN TWO RURAL COMMUNITIES IN
THE FEDERAL CAPITAL TERRITORY, ABUJA, NIGERIA
A DISSERTATION SUBMITTED BY
DR. ESOMONU, SABASTINE NDUBISI
MBBS (ABSU)
DEPARTMENT OF COMMUNITY MEDICINE
UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU
TO
THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
IN PART FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE
FINAL FELLOWSHIP OF THE MEDICAL COLLEGE IN PUBLIC HEALTH (FMCPH)
MAY, 2017
1
DECLARATION
I hereby declare that this dissertation titled “COMPARATIVE ASSESSMENT OF UTILISATION
OF MATERNAL AND CHILD HEALTHCARE SERVICES IN TWO RURAL COMMUNITIES
IN THE FEDERAL CAPITAL TERRITORY, ABUJA, NIGERIA.” is my original and individual work.
It was written under the supervision of Dr. Emmanuel A. Nwobi.
I also declare that this dissertation has not been submitted anywhere else in part or in full for any other examination or any publication.
______Dr. ESOMONU, SABASTINE NDUBISI Department of Community Medicine University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu.
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CERTIFICATION
I hereby state that this dissertation was written by Dr. Esomonu, Sabastine Ndubisi under my direct supervision in the Department of Community medicine, University of Nigeria Teaching
Hospital, Ituku-Ozalla, Enugu.
Supervisor:
______DATE: ______Dr. Emmanuel A. Nwobi Department of Community Medicine, UNTH, Ituku-Ozalla, Enugu.
Head of Department:
______DATE: ______Prof. Chika Onwasigwe Head of Department, Community Medicine,
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UNTH, Ituku-Ozalla, Enugu.
ACKNOWLEDGEMENT
I wish to thank my supervisor, Dr. Emmanuel A. Obi, for his guidance and support throughout my residency training and for taking the pains to go through this project at all stages of its development.
I am also indebted to the Head of Department of Community Medicine at the University of Nigeria
Teaching Hospital, Enugu, Professor BSC Uzochukwu for his encouragement, and to other senior fellows in the department, including Prof. Chika Onwasigwe, Prof. Christopher Obionu, and Prof.
M. N. Aghaji.
I would like to appreciate Dr. Mathew Ashikeni, Dr. Hadiza Balarabe, Dr. Rilwanu Mohammed, and Dr. Daniel Gazama at the Federal Capital Territory Primary Healthcare Board, Abuja, who laid good foundations for my residency training and continued to support me throughout the training. I wish to also thank my employers and colleagues at the FCT Health Department, Abuja, especially
Dr. Mike Aghahowa and Dr. Frank Alu for being instrumental to my release to undergo residency training at Enugu and for their immense support and guidance throughout the years.
I cannot forget the wonderful assistance and co-operation I received from the leaders of the two communities, the heads of health department at the two area councils, the health facility managers, my research assistants, and all the participants in this study.
I thank my dear wife, Mrs. Ijeoma Appolonia Esomonu, and my children for their endurance, love, and steadfastness all through the years of my training out of Abuja.
Finally, I give all honour and glory to the Almighty God who saw me through it all.
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DEDICATION
This dissertation is dedicated to my lovely wife, Mrs Ijeoma Appolonia Esomonu and my children,
Obinna, Chidozie, Chinenye and Ifeoma.
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TABLE OF CONTENTS
Title Pages Title page i Certificaion ii Declaration iii Acknowledgement iv Dedication v Table of contents vi List of Tables viii List of acronyms ix Summary x Definition of Terms xii
CHAPTER ONE (INTRODUCTION) 1 1.1 Background Information 1 1.2 Problem Statement 4 1.3 Justification 5 1.4 Research Questions 6 1.5 General and specific objectives 6 1.6 Hypothesis 6
6
CHAPTER TWO (LITERATURE REVIEW) 7 2.1 Goals of MCH and indicators for monitoring services 7 2.2 Determinants and utilisation of MCH services 7 2.3 Perception of women on maternal and child healthcare services 12
CHAPTER THREE (MATERIALS AND METHODS) 14 3.1 Description of study Area 14 3.2 Study design 16 3.3 Study Population 16 3.4 Sample size determination 16 3.5 Sampling technique 17 3.6 Data collection tools 18 3.7 Method of data collection 18 3.8 Data management 19 3.9 Ethical considerations 20 3.10 Limitations 20
CHAPTER FOUR (RESULTS) 21 4.1 Socio-demographic characteristics of women in the study area 21 4.2 Perception of MCH services among women in the study area 24 4.3 Utilisation of MCH services among women in the study area 26 4.4 Factors associated with utilization of MCH services among women in the 34 study area 4.5 Predictors of utilization of MCH services among women in the study area 46
CHAPTER FIVE (DISCUSSION) 51
CHAPTER SIX (CONCLUSIONS AND RECOMMENDATIONS) 57
REFERENCES 58
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APPENDICES 72-82 - Participant information sheet
- Informed consent form
- Questionnaire for the women
- Ethical clearance
- MAP of FCT showing the study area
LIST OF TABLES
Table 1 Socio-demographic characteristics of women in the study area 21-22
Table 2 Basic items owned by household women in the study area 23
Table 3 Perception of MCH services among women in the study area 24
Table 4 Utilisation of ANC among women in the study area 26
Table 5 Utilization of delivery/post-natal services among women in the study area 27
Table 6 Utilisation of family planning services among women in the study area 29-31
Table 7 Utilisation of child OPD services among women in the study area 32
Table 8 Utilisation of Immunization services by children of women in the study area 33
Table 9 Factors associated with utilization of ANC among women in the study area 34
Table 10 Factors associated with utilization of delivery services among women in the study area 36
Table 11 Factors associated with utilization of post natal services among women in the study area 38
Table 12 Factors associated with utilization of family planning services among women in the area 40
Table 13 Factors associated with utilization of child OPD services among women in the study area 42
Table 14 Factors associated with utilization of immunization services by children of women in the 44 study area
Table 15 Predictors of utilization of delivery services among women in Kuchimbuyi community 46
Table 16 Predictors of utilization of post natal services among women in Kilankwa community 47
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Table 17 Predictors of utilization of family planning services among women in Kuchimbuyi 48 community
Table 18 Predictors of utilization of family planning services among women in Kilankwa 49 community
Table 19 Predictors of utilization of immunization services by children of women in Kuchimbuyi 50 community
LIST OF ACRONYMS AIDS Acquired Immuno-Deficiency Syndrome ANC Ante Natal Clinic CEOC Comprehensive Emergency Obstetric Care CHEW Community Health Extension Worker CHO Community Health Officer DHS Demographic and Health Surveys
DPT3 Diphtheria/Pertussis/Tetanus Toxoids immunization (3) EMONC Emergency Obstetric and Neonatal Care FCT Federal Capital Territory FGD Focused Group Discussion HEACM Health Advocacy and Community Mobilization HIV Human Immuno-Deficiency Syndrome
IEEC Information & Education for Empowerment & Change IMCI Integrated Maternal, Newborn and Childhood Illnesses JCHEW Junior Community Health Extension Worker MCH Maternal and Child Healthcare MDGs Millennium Development Goals
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MSS Midwives Services Scheme NPI National Programme on Immunization NDHS National Demographic and Health Survey OPD/POPD Out-Patient Department/Paediatric Out-Patient Department
PENTA3 Pentavalent Vaccine (3) PHC Primary HealthCare PHCB Primary Health Care Board SVCT Standard clinic-based Voluntary Counselling and Testing SURE-P Subsidy Re-investment and Empowerment Programme TBAs Traditional Birth Attendants TT Tetanus Toxoids UNICEF United Nations Children’s Fund VCT Voluntary counselling and Testing WHO World Health Organization SUMMARY
Maternal and Child Health (MCH) refers to the broad means of providing promotive, preventive, curative and rehabilitative health care for mothers and children. Due to the fact that the health status of the mother is vital to the survival and well being of children and the family, there is the need for integration of maternal and child health care programmes.
The objective of the study was to assess and compare the utilization of MCH services among women in two rural communities in the Federal Capital Territory of Nigeria.
The study employed community-based comparative cross-sectional design to assess and compare the utilization of MCH services among women in two rural communities. Four hundred women from the two communities were selected using a multistage sampling technique and data was collected using a pre-tested, interview-administered questionnaire.
The study showed that women in both study communities had good and comparable perception of
MCH services. They however had low and variable levels of utilization of MCH services; these
10 include use of ante natal, delivery, post natal, family planning and child health services. The utilization of MCH services significantly associated with age groups, religion, marital status, occupation, income and education of women in the two study groups.
Sustained public enlightenment of rural dwellers (particularly women) on benefits of utilizing health facilities is required to enable them make better use of available health services. Relevant stakeholders should also develop modalities to overcome the social-cultural factors that inhibit optimal utilization of MCH services in rural communities. Furthermore, the findings of this study should be disseminated to the LGAs and FCT authorities so as to assist them to improve the current situation and to encourage more operational researches in this important area of public health.
Key words: Women, Rural Area, MCH Services, FCT.
DEFINITION OF TERMS
The elements of Maternal and Child Healthcare (MCH) include; pre-marital care, antenatal care, institutional deliveries, skilled attendance at delivery, postnatal care, child welfare/immunization clinics.
Pre-marital care involves a number of primary preventive measures aimed at preparing an adolescent woman adequately for the next level of reproductive period. These include screening for diseases and genetic counselling, prevention of sexually transmitted infections, prevention of drug abuse and alcoholism, prevention of unwanted pregnancy, and immunization.
Antenatal Care is the healthcare and education provided during pregnancy which aims to ensure good health for the mother and her unborn child. Antenatal visits provide opportunities for establishing and recording key facts regarding a woman’s health and obstetric past which assists in
11 the identification of problems, and thus provide criteria for appropriate decision making about healthcare given.
Institutional Deliveries refer to deliveries in public and private hospitals, clinics and health centres, regardless of the personnel that attended to the deliveries, the ultimate aim being achievement of healthy mother and child with the least possible interventions.
A skilled attendant is one who has proper training and a range of midwifery skills appropriate to the required level of service. It includes all categories of doctors and/or persons with midwifery skills who can diagnose and manage normal deliveries, as well as obstetric complications, in addition to providing support for the woman and her family.
Postnatal care: Refers to care given to a woman from the time of delivery of the placenta up to six weeks postpartum during which the body returns to its pre-gestational state. It provide opportunity for adequate breastfeeding, discussions for family planning, and for diagnosis and treatment complications.
Child welfare/immunization clinics provide services for children under school age and their families. The aim of the child welfare clinic is to ensure as good health as possible for each child and to promote the wellbeing of the whole family. The goal is to promote healthy lifestyles in the family and to identify and remove, whenever possible, the obstacles to the child’s healthy development. The work forms include health check-ups and examinations, weighing, vaccinations and individual health guidance, as well as home visits and small-group activities.
Social mobilization is a process of bringing together all feasible inter-sectoral, social/professional partners and allies, enlisting their support in garnering all the resources of a community for the achievement of felt need.
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Community support includes all methods of providing support for individuals and group of people within a community through organised efforts. It also includes both direct and indirect support provided to members of a community who may find themselves in situations that require external assistance.
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND INFORMATION The term Maternal and Child Health (MCH) refers to the broad means of providing promotive, preventive, curative and rehabilitative healthcare for mothers and children. It includes various services and programmes organized to provide medical and social services for mothers and children aimed at reducing morbidity and mortality among them.1 According to the World Health
Organization (WHO), the elements of MCH include; pre-marital care, antenatal care, institutional deliveries, skilled attendance at delivery, postnatal care, child welfare/immunization clinics.2
Pregnancy and childbirth are special events in the lives of every woman and members of their families; they can be period of great hopes and joyful expectations, but it can also lead to a lot of anxieties, suffering and even death.3
Every year, more than 200 million women become pregnant with 15% of them likely to develop complications that will need skilled obstetric care to avoid deaths and disabilities.3 Women and children form majority of the population in most countries, especially in the developing countries where they constitute up to two-thirds of the total population and are known to be particularly vulnerable to genetic and other complex interplay of environmental factors that may result in high
13 morbidities and mortalities, as well as other serious disabilities.4 It is therefore very desirable to design special programmes that will uplift the health status of women and children.
Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the site or duration of the pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes.4 It is measured by the number of deaths of women during pregnancy, labour and peuperium within a given period of time per 100,000 live births (maternal mortality ratio) or by the number of maternal deaths per 100,000 women of child-bearing age (maternal mortality rate). The causative factors of maternal mortality in developing countries include both direct and indirect obstetric factors, as well as non-obstetric factors.4-6
The direct obstetric factors include ante-partum and post-partum haemorrhages, eclampsia, obstructed labour, sepsis/infection, unsafe abortion, and anaemia in pregnancy. Indirect obstetric factors are usually disease conditions that predate or occur during pregnancy but are however aggravated by the pregnancy and they include malaria, diabetes mellitus, tuberculosis, cardiovascular diseases (e.g. Hypertension), HIV/AIDS, and sickle cell disease. Non-obstetric causes of maternal mortality are factors that relate with access to maternal health services and socio-cultural conditions. Examples include lack of adequate equipment, shortage of staff/required expertise, cultural and religious beliefs, poverty, low social status of women, poor road networks and efficient public transportation system, lack of family planning services, early marriages, multiparity and primiparity, etc.
Most maternal deaths and millions of cases of disease and disabilities arising from pregnancy and/or childbirth come from highly preventable causes and conditions. Effective preventive approaches to minimize or eradicate these problems will include: Basic maternal care for all pregnancies,
14 including a skilled attendant at birth; Prevention and treatment of complications during pregnancy, delivery and after birth; and Post-partum family planning.7
Child mortality, also known as under-5 mortality, refers to the death of infants and children under the age of five and accounts for approximately 40% of the total mortality in most developing countries, about half of which occur in sub-Saharan Africa where 1 in 9 children dies before age five.2,8 Furthermore, infant mortality rate refers to the death of a child within the first year of life and is regarded as an important index of child health as well as sensitive measure of the effectiveness of health services and socioeconomic progress of any country.5 The most common killers of children in developing countries are diarrhoea, pneumonia, malaria, tuberculosis, measles, worm infestations, protein energy malnutrition, whooping cough, anaemia and domestic accidents.4
Because the health status of the mother is vital to the survival and well being of the children and the family, there is every need for integration of maternal and child health programmes. The United
Nations Millennial summit of September 2000 went further to demonstrate significant commitment towards reduction of maternal and child mortalities by adopting the 4th and 5th of the eight
Millennium Development Goals (MDGs) aimed at reversing the large scale deaths and ill-health ravaging the world to be achieved by year 2015.4
Most vulnerable communities with the highest numbers of newborn and maternal mortalities have made efforts to develop and implement culturally appropriate solutions to improve the health of mothers and children which have lead to substantial reduction in maternal and child mortalities through the use of strategies that depend on antenatal services as effective points of contact with the target populations.9-10 However, low utilization of MCH services remain prevalent in most developing countries, making control programmes that rely solely on delivery of MCH services to record poor coverage and compliance.11-14 A number of factors have been identified as determinants of utilisation of MCH services in the developing countries. These include; access to emergency
15 obstetric, neonatal and child health services; financial power; socio-cultural factors; and access to information.17-19
1.2 PROBLEM STATEMENT
The indices for maternal and child mortality are relatively high in most developing countries, particularly in sub-Saharan Africa. Nigeria has one of the worst indicators in the world where maternal mortality ratio is as high as 530/100,000 live births, infant mortality rate stands at 88/1000 live births and an under 5 mortality rate is estimated to be 142/1000 live births.7,20-21 Globally, at least 1,600 women die from the complications of pregnancy and childbirth daily, giving an annual figure of 585,000 women (with Nigeria alone contributing up to 10% of the figure), and over 50 million more women suffer from acute complications and long term morbidities. In Nigeria, where about 5,323,000 women become pregnant annually, about 800-1500 women die in every 100,000 live births, implying that 1 in every 13 women are at a lifetime risk of maternal death compared with 1 in 5,100 in the UK and 1 in 7,700 in Canada.3,22
Available figures indicate that only about 65% of women in developing countries receive antenatal care, compared with 79% for the developed countries. Furthermore, only 40% of deliveries in developing countries take place in health facilities, while only 53% of the deliveries are attended to by skilled personnel, compared with estimated figures of 98% and 99% respectively in developed countries.3,6 Although cost-effective and feasible measures may be available for prevention of maternal deaths and disabilities arising from pregnancy and child births, the interventions are not usually utilized in many developing countries.11,23
Data from Nigeria shows that the high maternal mortality rates and poor childhood indices may be partly due to low coverage for MCH services with the revelation that about 36% of pregnant women do not receive antenatal care (ANC), only 36.3% of them received skilled attendance at delivery, while 33% of deliveries took place in health facilities, immunization coverage was between 32.8%
16 and 60%, while less than 20% of children were fully immunised at age one.22,24 The loss of lives of mothers and children can be attributed to three main delays in the process of accessing healthcare.
These include; (a) the delay in recognizing life threatening conditions and in decision to seek care
(b) the delay in reaching a health facility, and (c) the delay in receiving care after reaching the health facility.4,25 It has however been established that most cases of maternal deaths occur between the third trimester and first week after delivery, underscoring the need to avoid the delays and for provision of skilled care at delivery.26-28
Nigeria was rated as the eighth worst-performing country amongst 148 nations of the world in the
WHO/UNICEF 2007 “state of the world’s children report” which put the country’s infant mortality rate at 189 deaths per 1,000 live births. The report further revealed that Nigeria records about
5,300,000 annual births out which about 11,000 die daily, with more than 61% of deaths occurring within the first 24 hours of life, while approximately 163,400 of them were stillborn.29 Some of the identified causes of these deaths and disabilities in children include poor maternal health, inadequate care, poor hygiene and inappropriate management of delivery, lack of newborn care, malaria, pneumonia, diarrhoea, measles, and HIV/AIDS.
1.3 JUSTIFICATION FOR THE STUDY
It has been shown that a strong relationship exist between maternal/child mortalities and effective access to timely healthcare delivery, especially emergency obstetric and neonatal care (EMONC) services. Although the number of mothers that attend antenatal care at least once during pregnancy in Nigeria is reasonably high (65%), the preference for Traditional Birth Attendants (TBAs) at delivery has remained a persistent practice which continues to deny women of the benefits of adequate care.30-31
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It is necessary to determine the factors that influence the degree of patronage of health facilities in this part of the world. Several solutions have been propounded to arrest the ugly phenomenon, including provision of basic maternal care and skilled attendants at birth, prevention and treatment of complications during pregnancy/delivery, family planning and community mobilization.32 This study therefore wishes to assess the utilisation of MCH services in rural communities of Federal
Capital Territory of Nigeria and the factors that determine utilization of the services in the area. The study will no doubt further contribute to research on utilization of Maternal and Child Health Care services in Nigeria and Africa.
1.4 RESEARCH QUESTIONS
1. What is the perception of women in rural communities of FCT regarding MCH services?
2. What is the level of MCH services utilisation among women in rural communities of FCT?
3. Is there any difference in utilization of MCH services in rural communities of the FCT?
4. What are the factors that determine utilisation of MCH services in rural communities of FCT?
1.5 GENERAL AND SPECIFIC OBJECTIVES
1.5.1 Aim (general objective)
The aim of the study is to assess and compare the utilization of maternal and child healthcare services among women in two rural communities of Federal Capital Territory, Abuja, Nigeria.
1.5.2 Specific Objectives
1. To assess and compare perception of MCH services among women in two rural communities in FCT.
2. To assess and compare utilisation of MCH services among women in two rural communities in FCT.
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3. To identify the factors associated with utilization of MCH services among women in rural communities of FCT.
1.6 HYPOTHESES
1. The null hypothesis: There is no difference in the utilization of maternal and child healthcare services (such as child OPD, immunization, ante natal and post natal clinics, and deliveries) among women in rural communities of the Federal Capital Territory, Nigeria.
2. The alternative hypothesis: There is difference in the utilization of maternal and child healthcare services among women in rural communities of the Federal Capital Territory, Nigeria.
CHAPTER TWO
LITERATURE REVIEW
2.1 GOALS OF MCH AND INDICATORS FOR MONITORING SERVICES
During the world summit for children in 1990, WHO and the United Nations Children’s Fund
(UNICEF) adopted two goals with direct relevance to safe motherhood, and subsequently proposed five indicators for national monitoring, programme management and international reporting.33 The two goals were (i) reduction of maternal mortality by half between 1990 and the year 2000 and (ii) provision of access by all pregnant women to prenatal care, trained attendance during childbirth and referral facilities for high-risk pregnancies and obstetric emergencies.
The recommended indicators to monitor the goals included: (i) Maternal mortality rate/ratio (ii)
Annual number of maternal deaths (iii) Proportion of women who attend ANC at least once during pregnancy by trained personnel (iv) Proportion of births attended by trained health personnel and
(v) Number of facilities providing essential obstetric care per 500 000 population. These process indicators provided descriptive information on the performance of maternal health programmes.
Though facility-based information offers great opportunity for continuous collection and recording of health data, there is the tendency to exclude a number of private health facilities in the process;
19 thus community-based information will certainly provide complementary sources of information for health services utilization.34
2.2 DETERMINANTS AND UTILISATION OF MCH SERVICES
The WHO estimates show large disparity in the proportion of population receiving MCH services in the developed and developing countries, with Africa having the lowest coverage rates of 63% for antenatal care, 36% for institutional deliveries, and 42% for skilled deliveries.6 However, global findings from within the regions presents variable results. A study in China showed that 54.8% of women had at least one pre-natal care visit, 27.5% gave birth in a health care facility, and 18.1% had post-natal check-up. Utilization was found to be inversely related to age and parity and positively related to education.35
Another cross-sectional study from southern India reported very high utilization rate of 92% for government facilities compared with 54% use for private facilities, though child deliveries at home by untrained attendants were high. In other to improve utilization and access, it recommended that community health needs assessment and attempts to develop community participation should be made.36 On the other hand, available data from the 1996-97 Bangladesh Demographic and Health
Survey (DHS) indicate that almost three-quarters (71%) of births in the preceding 5 years were to women who did not receive antenatal care, with 95% of births occurring at home, 57% were assisted by untrained TBAs and only 8% being assisted by medical personnel.37
A cross-sectional study on indicators for availability, utilization and quality of emergency obstetric care in selected health facilities in Ethiopia found that few facilities met the UN standards of 5 per
500,000 population. Details revealed that only 7% of deliveries took place in institutions of any type, only 3% of the facilities provided all the signal functions for delivery, while only 6% of women with obstetric complications were treated in any health facility.38 A similar community- based study on utilization of skilled birth attendant among women of child-bearing age in the same
20
Ethiopia recorded 58.9% utilization of skilled birth attendant at delivery and 45% home delivery.
Women who had formal education and those who had ANC visits were more likely to utilize skilled delivery services than those who did not have education and/or ANC visits. Gaps were observed between users and providers despite more than average utilization recorded. It was recommended that community members should discourage harmful traditional and usual practices that hinder health facility delivery care utilization.39
Another cross-sectional study among women of reproductive age in a rural district in Cameroon revealed high utilization of MCH services among them. About 98.4% of the women utilized ANC services during their most recent pregnancy, among which 87.4% made at least four ANC visits and all had their deliveries in a health facility. Lower educational status was associated with better male partner involvement in utilization of PMTCT.40
Available literature on utilization of maternal and child services in Nigeria date back to the 1980s.
A published study on utilization of MCH services around Kainji Lake in 1989 showed that 80% of pregnant women sought maternal care from the traditional midwives and 95% of families had child spacing of between 1-3 years.41 Another study in Ile-Ife in 1992 involving 896 women showed that
74.6% claimed they received TT during pregnancy out of which 4.1% was confirmed and about
35% of them delivered their babies either at home or in the Church.42
A cross-sectional study on utilization of free MCH services among 150 women of child-bearing age in south-eastern Nigeria recorded a utilization of 55.3% for ANC, 47.3% for maternal tetanus toxoid immunization and 44% for childhood immunization, while family planning service was the least utilized (12%). Majority of the women (86.7%) were satisfied with the services they received and were willing to continue to utilize the services rendered at the health centres. Facilities records further showed that the introduction of free MCH services lead to significant increase in MCH services utilization between 2007 and 2009.43 In a study on the maternal health-seeking behaviour and associated factors in a rural Nigerian community, the authors found that only 9.9% received
21 antenatal care, while 4.9% attended postnatal clinic.44 Majority of the women (37%) preferred to deliver in private establishments, followed by traditional birth attendants (25.5%), and government facility (15.7%). There was significant association between education and choice of place for delivery, but no association was found with respect to age and marital status.
A number of factors have been identified as determinants of utilization of MCH health services some of which act as positive or negative predictors of utilization. These include demographic, socio-economic level, educational attainment, health insurance coverage, cultural norms, parity level, ethnicity, religion, social influence from spouse and other relatives, and health system factors.17-19,45-46
In the Philippines, pregnant women who had professional or white collar jobs were significantly more likely than those not employed for pay to have prenatal care and to adopt a contraceptive method after childbirth, while other studies from north Africa showed that a high standard of living was associated with increased use of antenatal care and hospital delivery by 50% and that spouse’s education was associated with increased utilization rates of 18% and 34% in Tunisia and Morocco respectively.47-48
In Swaziland, socio-demographic factors such as woman's age, parity, media exposure, maternal education, wealth quintile, and residence act in different ways to influence use of maternal and child health services. Increasing age and higher number of children were associated with lower utilization of services, while higher maternal education and exposure to media positively influenced use of services. Furthermore, higher wealth quintile and urban residence were associated with higher utilization of MCH services.49 These were collaborated by findings from similar studies in Kenya and Uganda which showed that higher education, richest wealth status, exposure to media and having employment or business were associated with higher utilization of MCH services; While
22 older age and having higher number children were associated with lower utilization of the services.50-51
Furthermore, a cluster survey among rural population in Liberia showed that living at a distance from health facility is associated with reduced utilization of MCH services. Those who lived in the farthest quartile had lower odds of attending ANC check-up, delivering in a facility, getting postnatal care and their children receiving de-worming treatment.52 Meanwhile, a study in Ghana revealed that women who are more autonomous and who perceive positive attitudes toward facility delivery were more likely to deliver in a facility and the effect of decision-making autonomy is more important for women who live in communities that are less supportive of institutional delivery compared to communities that are more supportive. While low level of education, wrong knowledge of the required period for ANC attendance, inadequate knowledge of the benefits of
ANC and non-participation in the behaviour change communication sessions were reported as factors associated with low utilization of ANC services in southern part the republic of Benin.53-54
The association between socio-economic and cultural characteristics of women and utilization of
ANC services was equally shown in other studies in Nigeria. A study in the south east of Nigeria found that introduction of free maternal and child health care caused tremendous increases in the uptakes of antenatal booking (202.2%) and hospital delivery (151.8%). The intervention also resulted in decreased maternal and perinatal mortality by 16.4% and 34% respectively.55 Another study on non-uptake of facility-based maternity services in an inner-city community in Lagos, found that about 51.4% of the women delivered outside hospital facilities, while 81.8% had no skilled attendants at delivery. Non-hospital delivery or the presence of unskilled attendants at delivery were associated with teenage mothers, Muslim religion, low or middle social class and use of herbal drugs in pregnancy, ethnicity (Yoruba tribe), lack of tertiary education or full-time employment, accommodation with shared sanitation facilities and multiparity.56
23
A similar Nigerian study also confirmed consistency of associated between non-utilization of postnatal care services and distance, education, place of delivery, region and wealth status of women with the result that 63% of mothers and about 42% of those aged 25-34 years did not utilize postnatal care services. In addition, about 61% of those who did not utilize postnatal care had no education.57 Another study in Nigeria found that though a functioning government maternity centre in the community offered a full range of antenatal and delivery services, most of the women did not register for antenatal care until their sixth month of pregnancy or later, and 65% delivered at home.
This behaviour is explained in terms of (a) fees for delivery services, (b) level of income, (c) cultural beliefs, and (d) education.58
2.3 PERCEPTION OF WOMEN ON MATERNAL AND CHILD HEALTHCARE SERVICES
Perception of maternal and child health services can go a long way to influence its utilization by mothers and members of their families which could in turn impart on the general well being of the community. A qualitative study in a rural district of India indicates that women and other members of the community had positive perception towards ANC services in the district health facilities. But, the people were more critical about hospital care during the time of delivery, particularly with regard to health workers’ attitude and disposition towards the women which went a long way to affect service utilization.59 High perception index for MCH services was also recorded in a mixed study in two districts of Bangladesh where more than 87% of respondents were satisfied with the services at three levels of care despite the reported inadequacies in the facilities such as poor logistic and laboratory support and lack of healthcare personnel. This was however attributed to low educational status and low socio-economic background of majority of people in the area which affected their knowledge of their basic rights.60
24
A systematic review of studies on perceptions of women and communities on pregnancy and obstetric services in Sub-Saharan Africa identified community attitudes regarding cultural beliefs and interactions with healthcare providers as barriers to the utilization of healthcare services during pregnancy in the sub-region, which in turn prevent engagement with prenatal care and timely use of medical services.61 Addressing the barriers therefore will be seminal to the success of any healthcare intervention. Another community-based study in Gondar Zuria district of Ethiopia reported that women had a high level of awareness and perception about the necessity of post-natal care, and urban women and those who displayed higher levels of autonomy were more likely to use postnatal health services.
About 84.39 % of women were aware and 74.3% of them perceived it necessary to utilize post-natal care, while 66.8 % utilized the service. Factors associated with positive perception of postnatal services included younger age, urban residence, close location of health facility, multiple ANC visits and awareness of post- natal care.62
A similar study in Malawi revealed that parents’ perception of postnatal care and their knowledge of maternal morbidity and mortality play a vital role in the uptake of postnatal care. Though most perceived pregnancy and childbirth as the most risky periods to women, established barriers to utilization of postnatal care were lack of the knowledge, long waiting time for treatment, and separation of the mother and baby care in health facilities. It recommended institutionalization of health education programs about maternal health to parents and community members.63 Two related studies on perception of antenatal and delivery care service utilisation in urban and rural districts of Kenya reported that both men and women had good perception and positive dispositions towards MCH services. There was a very strong association between women's perceptions of access to and quality of care, and facility deliveries; and the men often encouraged, some even ‘forced’, their wives to attend for antenatal or delivery care.64-65 The perceived role men as sole providers, negative health care worker attitude towards men’s participation, and infrastructural deficits were some recorded barriers to service utilization among women in the areas.
25
A household survey among mothers in the south east of Nigeria recorded that majority of the women rated MCH services good in available public health facilities, with 89% of them willing to pay for health services if drugs were readily available. Specific perceived satisfactions for MCH services were 95.9% for childhood immunization, 94.3% for antenatal care and 95.8% for delivery services. However, long waiting queues, providers' behaviours and lack of doctors militated against their overall utilisation of MCH services.66 Another Nigerian study among women utilizing PHC facilities in a district reported that majority of the respondents had good perception of and satisfactory disposition to available MCH services, as well as good opinion towards the cost of services and attitude of health care personnel. Furthermore, the socio-demographic characteristics of women were not found to be associated to their perception of MCH services.67
CHAPTER THREE
MATERIALS AND METHODS
3.1 STUDY AREA
The Federal Capital Territory (FCT) is located at the centre of Nigeria and has a land area of about
8,000 square kilometres. It is bounded in the north by Kaduna State, southeast by Nasarawa State, southwest by Kogi State and the west by Niger State.68 FCT has isolated highlands with savannah grassland and tropical rain forests with fertile soil suitable for diverse agricultural activities. The territory experiences two weather conditions annually; these are the rainy and dry seasons. The
Nigeria’s 2006 census put the population of FCT at about 2 million, consisting of the indigenous people, other Nigerians and foreigners with the population of women of child-bearing age estimated to be 370,683 (26.7%) and under-five children was 271,770 (20%).98 However, 2015 projected population of FCT stands at about 4.185 million based on the annual growth rate of 9.3%.69
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FCT is divided into six administrative area councils namely; Kuje, Gwagwalada, Bwari, Kwali,
Abaji and Abuja Municipality with over 60% of the populace living in the rural areas.68,70 Each area council has at least one public secondary and up to 20 public PHC facilities. This study was conducted in Kuchinbuyi village in Bwari, and Kilankwa village in Kwali area councils which are located about 115 Kilometres apart and at opposite ends of FCT (see FCT Map at appendix).
Bwari area council is located about 45 kilometers north east of Abuja city and has a total landmass of 29,625km2 with a population of 229,274.69 The council is predominantly inhabited by Gbagyi, in co-existence with other ethnic groups such as Hausa, Igbo, Yoruba, and others.69 In 2011, estimates of PHC facility activities showed that ANC attendance was 17,705, out-patient attendance was
19,590, Total deliveries was 6,309, family planning clinic attendance was 8,739, and DPT3 coverage was 12,138 out of the 14,178 target.71
Kuchinbuyi is a rural community located in Bwari area council, west of Bwari town, the headquarters of the area council. Majority of the people are of Gbagyi tribe and Christians, though
Hausa language is widely spoken in the area. A considerable number of the people are farmers while others are involved in ceramic production and trading. The community has a PHC centre registered under the midwives services scheme (MSS) which has a total staff of 9 made up of 1
Community Health Officer (CHO), 4 Nurse/Midwives, 3 Community Health Extension Workers
(CHEWs), and 1 Junior CHEW. The facility also serves 7 other neighboring villages/settlements with a total of 503 households, total population of 11,189, 526 women of child-bearing age, and
2,151 under-5 children.72
Kwali area council of FCT covers a land area of about 1,206 square kilometres with a population of about 85,837 and located about 70km from Abuja municipality. The council shares boundary with
Gwagwalada, Kuje, and Abaji area councils. The main ethnic groups in the council are the Gbagyi,
Gade and Bassa.70 Other ethnic groups such as the Hausa, Fulani, Igbira, Ibo, Yoruba, and Tiv also
27 live here, while the major religions are Islam and Christianity. Estimates of 2011 PHC facility activities showed that ANC attendance was 5,011, out-patient attendance was 14,817, total deliveries was 654, family planning clinic attendance was 791, and DPT3 coverage was 4,070 out of the 5,356 target.71
Kilankwa is a rural community located in Kwali area council and east to Kwali town, the headquarters of the area council. Majority of the people are Gbagyi and Christians, while Hausa language is also widely spoken in the area. Similarly, considerable numbers of the people are involved in farming, trading and small scale businesses. The community has a PHC centre registered under the MSS which has a total staff of 19 made up of one CHO, 4 Nurse/midwives, 2
CHEWs, 1 J-CHEW, and 1 Laboratory scientist. The facility also serves 9 other neighboring villages/settlements with a total of 512 households, total population of 12,389, 509 women of child- bearing age, and 2,305 children of child-bearing age.72
3.2 STUDY DESIGN
This was a community-based comparative cross-sectional study involving two rural communities in two area councils of FCT, Nigeria and the variables of interest were utilization of MCH services.
Quantitative survey was carried out among women in the two communities to assess their perception and use of MCH services. The study team paid advocacy visits the stakeholders in both communities to inform them about the study, seek their support and obtain official permission.
3.3 STUDY POPULATION
The study population comprised of married and unmarried women of child-bearing age (15-49 years) in the selected communities.
3.3.1. Inclusion Criteria i. Married and unmarried women who had at least one delivery, and
28 ii. Those who met criterion ‘i’ who are permanent residents of the study community (those who resided in the community for at least one year before the intervention) were included in the study.
3.3.2. Exclusion Criteria
Women of child-bearing age who were not willing to participate were excluded from the study.
3.4 SAMPLE SIZE DETERMINATION
This was done using the following formula for comparing two independent proportions;73
2 N = 2 (Z α + Z1-β) x p(1-p)
d2 Where,
N = Minimum sample size for each group
Zα = Percentage point of standard normal deviate (2 sided) set at 95% confidence level =1.96
Z1-β = Power of the test set at 80% (20% B error) = 0.84
P = Rate of utilization of delivery services from a past Nigerian study = 57.1%74 d2 = Expected difference = 0.15
This gave n = 170. Twenty percent (20%) was added to the sample size to make up for attrition (ie
170 + 30) to give a total of 200. Therefore, 200 women were recruited from both the intervention and control communities which gave a total of 400 participants that were used for the study.
3.5 SAMPLING TECHNIQUE
Multistage sampling technique was used to choose the study participants.
Stage 1: Simple random sampling by balloting was used to select two out of the four rural area councils in FCT (Kwali, Abaji, Kuje, Bwari).75 Balloting was done separately for two rural councils that are located close to each other (ie. Kwali vs. Abaji and Kuje vs. Bwari) to avoid contamination
(See FCT Map at Appendix). Therefore, Bwari and Kwali councils were selected.
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Stage 2: Simple random sampling was also used to select one community from each of the two area councils using the list of communities that have PHC facilities operating the MSS as sampling frame. This was to ensure selection of communities with facility that provided equal scope of health services. Therefore, Kilankwa community from Kwali and Kuchimbuyi community from Bwari area councils were selected. Kuchimbuyi was further selected by simple random sampling through balloting to serve as the intervention community, while Kilankwa served as the control community.
Stage 3: In the two communities, households were selected through systematic sampling method using National Programme on Immunization (NPI) house numbering in the FCT-PHCDB’s data base as sampling frame.75 The sampling interval was determined by dividing the number of households in each community (sampling frame = 503 and 512) by the expected number of respondents (sample size = 200). Therefore, an approximate sampling interval of two was used for the two communities and the index households were selected by simple random sampling. In the selected households, women that met the inclusion criteria were selected and interviewed. Where there was no eligible woman, the adjacent household was selected.
3.6 DATA COLLECTION TOOLS
Data was collected by quantitative method using a semi-structured, interviewer-administered questionnaire. The questionnaire was pre-tested and validated using a sample of twenty women at
Gugugu village in Abuja Municipal Area Council of FCT. This helped in detecting any difficulty and ambiguity in the questionnaires and necessary corrections were effected.
A. The questionnaire contained open and close-ended questions consisting 5 sections labelled 1-5.
Section 1: Socio-demographic characteristics of respondents
Section 2: Perception of MCH services among the women
Section 3: Utilization of child OPD and immunization services
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Section 4: Utilization of antenatal, delivery and postnatal services
Section 5: Utilization of family planning services
3.7 METHOD OF DATA COLLECTION
The questionnaire was used to extract information from the study participants and data collection lasted for a period of two weeks. The questionnaire was administered in Hausa language by research assistants on the study participants in the two communities. Participants were identified in their respective houses using their house numbers and the questionnaires were administered on them at their convenient time (mainly on non-market days).
Research assistants (two per each community) who could communicate effectively in Hausa language were recruited and given further training by the researcher to administer the questionnaire.
The assistants were sourced from the pool of PHC workers of FCT Primary Health Care Board. The research team explained the purpose of the visit and obtained consent before questionnaires were administered to the eligible participants.
3.8 DATA MANAGEMENT
3.8.1 Measurement of Variables
The variables of interest in the study included the following;
1. Socio-demographic characteristics of respondents namely; age, marital status, tribe, religion, educational level, occupation, average monthly income, occupation of spouse, and basic house-hold items owned.
2. The indicators of child health service utilization included; (a) number of women who took their sick children to formal health facilities (private or public) and (b) number of women whose children aged less than one year received full doses of immunization.
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3. The indicators of maternal health service utilization included; (a) number of women who registered for ANC in formal health facilities (b) number of women who delivered their last children in formal health facilities (c) number of women using any method of family planning, and
(d) number of women who attended post-natal clinic after facility delivery.
4. The determinants of utilization of MCH services were assessed by exploring the association between socio-demographic characteristics of respondents (such as age, tribe, religion, education, occupation, average monthly income, husband’s occupation, number of living children, etc) and the utilization of MCH services in bivariate data analysis. Furthermore, multivariate analysis using logistic regression was done to determine the predictors of utilization of MCH services among the women. As a result, variables with logical sequence and those that had a level of significance of at least 20% were entered into the logistic regression model to determine the predictors of utilization of MCH services. Logistic regression model was fitted separately for utilization of Ante Natal, Post
Natal, Delivery, Family planning, Child OPD, and Immunization services, respectively. Results were reported using odds ratio, Confidence Interval at 95% and 5% significant level.
3.8.2 Statistical Analyses
Data collection and editing were done manually to detect omissions and ensure uniform coding, while entry and analysis were done electronically using the Statistical Package for Social Sciences
(SPSS) version 20. Frequency tables, cross-tabulations and graphs were generated for qualitative variables, while quantitative variables were summarized using means and standard deviation.
Statistical tests (such as student t-test, chi-square and logistic regression) were applied to test for differences between means and proportions, and for association between categorical variables.
Level of significance was pre-determined at a p-value of less than 0.05 (2-sided) at a confidence interval of 95%.
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3.9 ETHICAL CONSIDERATIONS
Written ethical clearance was obtained from the Research Ethics Committees of FCT health authority and the University of Nigeria Teaching Hospital, Enugu. Further requests for permission were made to the respective area councils’ health authorities and the health facility managers.
Informed consent was sought and obtained from the community heads and the study participants and they were further assured of confidentiality of their responses and information provided.
3.10 LIMITATIONS
The limitations of the study include the following;
1. The problem of interviewer bias on the part of research assistants who administered the questionnaires on the women was minimized by proper training of the research assistants and by validation of the questionnaires.
2. The possibility of incomplete/inaccurate information from the participants on utilization of MCH services was minimized by ensuring that the questionnaire was validated before data collection.
CHAPTER FOUR
4.0 RESULTS
4.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF WOMEN IN THE STUDY AREA
Table 1: The Socio-demographic characteristics of women in the study area.
Variables Kuchinbuyi Kilankwa χ2 p value
n= 200 n=200 N (%) N (%) Age of respondents Mean ± SD (years) 30.1±8.4 30.2±7.0 0.078* p=0.938
Age groups (in years) < 20 22 (11.0) 15 (7.5) 20 – 29 78 (39.0) 87 (43.5) 2.514 0.473 30-39 66 (33.0) 70 (35.0)
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40 And Above 34 (17.0) 28 (14.9)
Marital Status Married 158 (79.0) 149 (74.5) 1.135 0.287 Single** 42 (21.0) 51 (25.5)
Religion Christianity 124 (62.0) 109 (54.5) 2.313 0.128 Islam 76 (38.0) 91 (45.5)
Tribe Gbagyi 84 (42.0) 107 (53.5) Hausa/Fulani 45 (22.5) 38 (19.0) 5.392 0.067 Others 71 (35.5) 55 (27.5) *Student t-test **Never married, separated, or divorced.
Table 1 shows the socio-demographic characteristics of women of child-bearing age in the two study groups. The mean age of the respondents in the Kuchinbuyi was 30.1±8.4, while that in the
Kilankwa was 30.2±7.0 and majority of them were within the age group, 20-29 years, but the difference in proportions was not statistically significant. Majority of the respondents were married and from the Gbagyi ethnic group, but the differences were not statistically significant. However, a higher proportion of respondents from both study areas were Christians (62% and 54.5%), but this was not statistically significant.
Table 1: Socio-demographic characteristics of women in the study area, Continued.
Variables Kuchinbuyi Kilankwa χ2 p value
n= 200 n=200 N (%) N (%) Number of living children of respondents None 7 (3.7) 5 (2.5) 1 – 2 75 (39.7) 68 (34.0) 2.868 0.412 3 – 4 70 (36.5) 86 (43.0) 5 and Above 48 (20.1) 41 (20.5)
Educational Level No formal Education 41 (20.5) 55 (27.5) Primary 83 (41.5) 72 (36.0) 3.161 0.367 Secondary 61 (30.5) 56 (28.0) Post-secondary 15 (7.5) 17 (8.5)
Occupation of Women Farming 73 (36.5) 85 (42.5)
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Unemployed/Housewife 51 (25.5) 47 (23.5) 2.482 0.479 Self employed 56 (28.0) 45 (22.5) Salaried employment 20 (10.0) 23 (11.5)
Average monthly Income of Women Occupation of Husband n=158 n=149 Farming 79 (50.0) 72 (48.3) Unemployed 9 (5.7) 9 (6.0) 1.586 0.663 Self employed 52 (32.9) 44 (29.5) Salaried employment 18 (11.4) 24 (16.1) Higher proportion of respondents in Kuchinbuyi (39.7%) had 1-2 living children, while higher proportion of those in Kilankwa (43.0%) had 3-4 living children, but the difference in proportions was not statistically significant. In both study groups, lower proportions of the respondents were pregnant at the time of the survey (32.9% and 27.5%), but this was not statistically significant. Majority of women in both study groups had primary education (41.5% and 36.0%), while fewer proportion had post-secondary education (7.5% and 8.5%), but this was not statistically significant. Also, there was no statistically significant difference in the occupation of the respondents and that of their husbands. Higher proportion of respondents and their husbands in both study groups were farmers, while those with salaried employment were the least among them. However, there was a statistically significant difference in the average monthly income of the women, with a higher proportion of women who make less than N10,000 per month being more in Kuchinbuyi (78.5%), while higher proportion of those who make between N10,000-N29,999 are more in Kilankwa (23.0%), (χ2=8.461, p=0.038). Table 2: Basic items owned by household of women in the study area Variables Kuchinbuyi Kilankwa n = 200 n = 200 N (%) N (%) Basic items owned by household of women in the study area* 35 Radio/Television 117 (22.6) 123 (27.1) Kerosene lantern/Stove 120 (23.2) 106 (23.3) Motor cycle 94 (18.1) 77 (17.0) Rechargeable lantern 83 (16.0) 53 (11.7) Bicycle 49 (9.5) 46 (10.1) Fridge/Freezer 22 (4.2) 20 (4.4) Car 20 (3.9) 20 (4.4) Gas cooker 13 (2.5) 9 (2.0) *Multiple responses allowed The major items owned by household of respondents in both study groups were Radio/Television and Kerosene Lantern/Stove. Meanwhile, a higher proportion of those in Kuchinbuyi had Kerosene Lantern/Stove (23.2%), while higher proportion of those in the Kilankwa had Radio/Television. The least proportion of items owned by household of respondents in both study groups was Gas cooker (2.5% in Kuchinbuyi and 2.0% in Kilankwa), this was followed by Motor Car (3.9% in Kuchinbuyi and 4.4% in Kilankwa). 4.2 PERCEPTION OF WOMEN ON MCH SERVICES IN THE STUDY AREA Table 3: The perception of women on MCH services in the study area Variables Kuchinbuyi Kilankwa χ2 p value n = 200 n = 200 N (%) N (%) Perceived importance of Ante natal care Very important 80 (40.0) 64 (32.0) Important 84 (42.0) 92 (42.0) 2.941 0.230 Not important 36 (18.0) 44 (22.0) Perceived importance of Facility delivery Very important 52 (40.9) 40 (32.6) Important 81 (26.8) 89 (23.9) 2.058 0.357 Not important 67 (41.5) 71 (26.1) Perceived importance of Post natal care 36 Very important 58 (29.0) 52 (26.0) Important 122 (61.0) 109 (54.5) 7.178 0.028 Not important 20 (10.0) 39 (19.5) Perceived importance of Family planning methods Very important 47 (23.5) 61 (30.5) Important 78 (39.0) 87 (43.5) 6.471 0.039 Not important 75 (37.5) 52 (26.0) Perceived importance of Immunization for children Very important 33 (17.4) 40 (20.0) Important 99 (52.1) 114 (57.0) 2.858 0.240 Not important 58 (30.5) 46 (23.0) Level of satisfaction with MCH services at health facilities Very satisfied 32 (16.0) 24 (12.0) Satisfied 88 (44.0) 79 (39.5) 5.402 0.145 Dissatisfied 54 (27.0) 55 (27.5) Very Dissatisfied 26 (13.0) 42 (21.0) Table 3 above shows the perception of MCH services among women in the study area. A higher proportion of women in Kuchinbuyi (40%) perceived ANC as being very important than those in Kilankwa (32%), but the difference was not statistically significant. Also, a higher proportion of women in Kuchinbuyi (40.9%) perceived delivery services as being very important than those in Kilankwa (32.6%), but the difference was not statistically significant. Similarly, there was no statistically significant difference in the level of perception of facility childhood immunization among women in the two study groups. On the other hand, a statistically significant higher proportion of women in Kuchinbuyi (29%) perceived postnatal care as being very important than those in Kilankwa (26%), (χ2=7.178, 37 p=0.028); while a significantly higher proportion of women in Kilankwa (30.5%) perceived family planning as being very important than women in Kuchinbuyi (23.5%), (χ2=6.471, p=0.039). Furthermore, a higher proportion of women in Kuchinbuyi (16%) were very satisfied with MCH services they received at health facilities than those in Kilankwa (12%), while higher proportion of women in Kilankwa were very dissatisfied MCH services than those in Kuchinbuyi (13% vs. 21%), but the difference was not statistically significant. 4.3 THE UTILISATION OF MCH SERVICES AMONG WOMEN IN THE STUDY AREA Table 4: Utilisation of Ante Natal Clinic (ANC) among women in the study area Variables Kuchinbuyi Kilankwa χ2 p value n = 200 n = 200 N (%) N (%) Currently Pregnant? Yes 64 (32.9) 55 (27.5) 0.969 0.325 No 136 (68.0) 145 (72.5) Pregnant and attending ANC? n=64 n=55 Yes 41 (64.1) 36 (65.5) 0.025 0.874 No 23 (35.9) 19 (34.5) Stage of pregnancy when ANC n=41 n=36 registered Two months or less 2 (4.9) 14 (38.9) Three months 11 (26.8) 10 (27.8) 15.204 0.002 Four months 17 (41.5) 7 (19.4) Five months and Above 11 (26.8) 5 (13.9) 38 Reason for not registering for n=23 n=19 ANC in current pregnancy Not necessary/No proper advice 11 (45.8) 6 (31.6) No money 6 (25.0) 4 (21.1) Against my religion or culture 3 (12.6) 4 (21.1) 1.983 0.739 Health centre was far 2 (8.3) 3 (15.8) No reason 2 (8.3) 2 (10.5) Table 4 shows the utilisation of ANC among women of child-bearing age in the study area. At the time of the survey, a slightly higher proportion of respondents in Kuchinbuyi (32.9%) were pregnant compared with those in Kilankwa (27.5%), but the difference was not statistically significant. However, a slightly higher proportion of respondents in Kilankwa (65.5%) registered for ANC at health facilities in the current pregnancy, compared with 64.1% of those in Kuchinbuyi, but this was not statistically significant. On the other hand, a higher proportion of respondents in Kuchinbuyi registered for ANC at 4th month of pregnancy (41.5%), while higher proportion of those in Kilankwa (38.9%) registered at two months or less, and this was statistically significant (χ2=15.204, p=0.002). In both study groups, the major reasons why some women did not attend ANC in the current pregnancy was either because they did receive the proper advice or they didn’t think it was necessary to do so (45.8% vs. 31.6%). This was followed by lack of money and religious/cultural factors. But the difference in proportions was not statistically significant. Table 5: Utilization of delivery/post-natal services among women in the study area Variables Kuchinbuyi Kilankwa χ2 p value N (%) N (%) Delivered last child in a health facility 191 194 Yes 88 (46.1) 101 (52.1) 1.381 0.240 No 103 (53.9) 93 (47.9) Alternative places where last children n=103 n=93 were delivered At home 50 (48.5) 48 (51.6) 39 TBA 38 (36.9) 27 (29.0) 1.669 0.434 Religious Homes 15 (14.6) 18 (19.4) Reason for not delivering in health facility. n=103 n=93 Influence from family/friends 40 (38.8) 29 (31.2) No money 27 (26.2) 26 (28.0) Health facilities were far or closed 19 (18.4) 16 (17.2) 5.918 0.205 Not sure of quality of care at health facilities 9 (8.7) 5 (5.4) Others* 8 (7.8) 17 (18.3) Delivered in health facility and went for n=88 n=101 post-natal care? Yes 54 (61.4) 50 (49.5) 2.672 0.102 No 34 (38.6) 51 (50.5) Reason for not going for post-natal care n=34 n=52 I Was not told to come back 9 (26.5) 12 (23.5) Didn’t think it was necessary 7 (20.6) 9 (17.6) Distance 7 (20.6) 6 (11.8) 2.728 0.604 Influence from family/friends 5 (14.7) 14 (27.5) No reason 6 (17.6) 10 (19.6) *Include husband not at home, precipitate labour & preference for TBAs Table 5 above shows the utilization of delivery and post-natal services among women of child- bearing age in the study area. A slightly higher proportion of women in Kilankwa (52.1%) delivered their last child in a formal health facility than those in Kuchinbuyi (46.1%), but the difference was not statistically significant. Among those who delivered outside formal health facilities, a higher proportion of their deliveries were done at home in both study groups (48.5% and 51.6%). This was followed by deliveries conducted by the traditional birth attendants, followed by deliveries at religious homes, but the difference in proportions was not statistically significant. The major reason those who delivered outside formal health facility gave was because of influence of their friends and family members in both study groups (38.8% and 31.2%). This was followed by lack of money and the fact that the health facilities were either located too far from their homes or 40 they were closed when they came to have their deliveries, but the difference in proportions was not statistically significant. A higher proportion of women in Kuchinbuyi (61.4%) who delivered in formal health facilities utilized post natal services than those in Kilankwa (49.5%), but the difference was not statistically significant. The major reason given by women in Kuchinbuyi for non-utilization of post natal services was because they were not told come back (26.5%), while majority of those in Kilankwa did not utilize post natal services because of influence of their friends and family members (27.5%), but the difference in proportions was not statistically significant. Table 6: Utilisation of family planning services among women in the study area Variables Kuchinbuyi Kilankwa χ2 p value N (%) N (%) Currently using a family planning method? n = 200 n = 200 Yes 96 (48.0) 84 (42.0) 1.455 0.228 No 104 (52.0) 116 (58.0) If yes, which one? n=96 n=84 Injectables 43 (44.8) 47 (56.0) Condoms/OCPs 19 (19.8) 13 (15.5) Natural Method/Ex Breastfeeding 16 (16.7) 12 (14.3) 2.312 0.679 IUCD 13 (13.5) 9 (10.7) Implants/Tubal Ligation 5 (5.2) 3 (3.6) Reasons for the method of choice* n=96 n=84 It is cheap 40 (42.6) 41 (48.8) It is easy to use 52 (55.3) 62 (73.8) It has minimal side-effects 36 (38.3) 25 (29.8) It is readily available 57 (60.6) 41 (48.8) Others** 7 (7.4) 8 (9.5) Places where FP service was received n=96 n=84 41 Health centre 49 (51.0) 54 (64.3) Private Hospital 21 (21.9) 10 (11.0) TBA 18 (18.8) 12 (14.3) 4.566 0.206 Others*** 8 (8.3) 8 (9.5) Why not using any family planning method n=104 n=116 Husband/Religion did not approve it 33 (31.7) 27 (23.3) 32.001 <0.001 Afraid/Previous experience 21 (20.2) 39 (33.6) No Reason 17 (16.3) 29 (25.0) Not aware of it/Don’t believe in it 13 (12.5) 10 (8.6) High Cost 11 (10.6) 5 (4.3) Others**** 9 (6.7) 6 (5.2) *Multiple responses allowed **Low failure rate and advice from health personnel ***Chemist shops, religious homes ****Pregnancy, Yet to complete desired family size. Table 6 above shows the utilisation of family planning services among women of child-bearing age in the study area. At the time of the survey, a slightly higher proportion of women in Kuchinbuyi (48.0%) were using family planning methods than those in Kilankwa (42.0%), but the difference was not statistically significant. Also, a higher proportion of women in both study groups used injections as method of contraception (44.8% and 56.0%). This was followed by condom/Oral contraceptives, and Breast feeding/Natural methods, but the difference was not statistically significant. A higher proportion of those in Kuchinbuyi (60.6%) chose their methods of family planning because they were readily available, while higher proportion of those in Kilankwa (73.8%) made their choice because they were relatively easy to use. Majority of women in both study groups received family planning services at the community health centre (51.0% and 64.3%), followed by 42 those who received services at private health facilities and those that received at facilities managed by traditional birth attendants, but the difference was not statistically significant. On the other hand, there was a statistically significant difference in the reasons given by women who were not using any method of family in both study groups at the time of the survey. Higher proportion of women in Kuchinbuyi (31.7%) did not use any method of family planning because their husband or religion did not approve it, while higher proportion of those in Kilankwa did not use any family planning method because they were afraid or were cautious of previous bad experiences (33.6%), (χ2=32.00, p<0.001). Table 6: Utilisation of family planning services among women in the study area cont. Variables Kuchinbuyi Kilankwa χ2 p value N (%) N (%) How information on FP was received N=96 n=84 Health Personnel 39 (40.6) 49 (58.3) Family/friends 15 (15.6) 11 (13.1) Radio/TV 17 (17.7) 9 (10.7) 7.071 0.132 Women’s Forum 14 (14.6) 11 (13.1) Religious groups 11 (11.5) 4 (4.8) Had any bad experience with FP methods? n=138 n=117 Yes 47 (34.1) 38 (32.5) 0.071 0.790 No 91 (65.9) 79 (67.5) Kinds of experience with FP Methods n=47 n=38 Non-menstrual bleedings 10 (21.3) 9 (23.6) Stoppage of menses/unexpected pregnancy 6 (12.8) 5 (13.2) Abdominal pains/Heavy menses 14 (29.8) 9 (23.7) 0.806 0.938 Fever/Weight gain 12 (25.5) 9 (23.7) Unusual discharge/painful intercourse 5 (10.6) 6 (15.8) What was done after experience with family n=47 n=38 planning methods 43 Stopped usage 7 (14.9) 5 (13.2) Continued usage 8 (17.0) 8 (21.1) Consulted health personnel 22 (46.8) 17 (44.7) 0.338 0.987 Complained to my husband 6 (12.8) 4 (10.5) Did nothing 4 (8.5) 4 (10.5) The major source of information on methods of family planning for women in both study groups was from the health personnel (40.6% and 58.3%). This was followed by information from friends and family members, and information from Radio/Tv/women’s groups, but the difference was not statistically significant. Also, a slightly higher proportion of women in Kuchinbuyi (34.1%) had bad experience with use family planning methods than those in Kilankwa (32.5%), but the difference in proportion was not statistically significant. Similarly, there was no statistically significant difference in the kind of experiences women in the two study groups had with the different methods of family planning, as well as in the actions they took after their experiences. Table 7: Utilisation of child Out Patient services (OPD) services among women in the study area Variables Kuchinbuyi Kilankwa χ2 p value N (%) N (%) Take child to health facility when sick n=193 n=195 Yes 109 (56.5) 119 (61.0) 0.828 0.363 No 84 (43.5) 76 (39.0) Place(s) where children are usually n=193 n=195 taken to when they fall sick Health centre 93 (48.2) 109 (55.9) Private hospital 16 (8.3) 10 (5.1) 4.247 0.236 Traditional healers/Chemists 64 (33.2) 52 (26.7) Religious homes 20 (10.4) 24 (12.3) Reason for choice of treatment* n=193 N=195 Affordability of their care 86 (55.5) 61 (52.1) Caring attitude of their staff 81 (52.3) 45 (38.5) My believe in their practice 69 (44.5) 57 (48.7) Influence of family and friends 48 (31.0) 29 (24.8) Advice from health professionals 74 (47.7) 35 (29.9) Nearness to my residence 34 21.9) 22 (18.8) Others** 6 (3.9) 3 (2.6) 44 How often health education is received n=200 n=200 at the health facilities? Always 73 (36.5) 98 (49.0) Occasionally 107 (53.5) 85 (42.5) 6.419 0.040 Never 20 (10.0) 17 (8.5) *Multiple responses allowed. **No reason & Facility owned by religious group. Table 7 shows the utilisation of child OPD services among women in the study area. A slightly higher proportion of women in Kilankwa (61.0%) took their children to formal health facilities when they fall sick than those in Kuchinbuyi (56.5%), but the difference was not statistically significant. The major reason for choice of facilities for treatment of their children was affordability of care in both study groups (55.5% in Kuchinbuyi vs. 52.1% in Kilankwa), followed by caring attitude of staff at facilities (52.3%) in Kuchinbuyi and the belief in the practice at facilities (48.7%) in Kilankwa. Furthermore, statistically significant higher proportion of women in Kilankwa (49%) always received health education at the health facilities, compared with higher proportion of those in Kuchinbuyi (53.5%) who received health education occasionally (χ2=6.419, p=0.040). Table 8: Utilisation of Immunization services by children of women in the study area Variables Kuchinbuyi Kilankwa χ2 p value N (%) N (%) All children below 1 year fully vaccinated? n=68 n=75 Yes 35 (51.5) 48 (64.0) 2.299 0.129 No 33 (48.5) 27 (36.0) Why children <1 year not fully vaccinated n=33 n=27 I don’t believe/not aware of it 11 (33.3) 7 (25.9) Far distance/Time constraint 8 (24.2) 10 (37.0) 1.476* 0.831 My husband/Religion did not approve of it 7 (21.2) 6 (22.2) Occasional shortage of vaccines at health centre 4 (12.1) 2 (7.4) My child had reaction in the past 3 (9.1) 2 (7.4) *Fisher’s Exact Test (FT) Table 8 shows the utilisation of immunization services by children of women in the study area. A higher proportion of children of women in Kilankwa who were less than one year of age (64.0%) 45 received full vaccination (verified from vaccination cards) at the time of the survey than children of women in Kuchinbuyi (51.5%), but this was not statistically significant. Also, a higher proportion of children of women in Kuchinbuyi (33.3%) did not receive full doses of immunization because their mothers did not believe in immunization or they were not aware of its existence, while higher proportion of children of women in Kilankwa (37.0%) did not receive full immunization because of the far distance of the health facilities from their homes or because their parents did have enough time to take them to the health facilities. But the difference in proportions was not statistically significant. 4.4 FACTORS ASSOCIATED WITH UTILIZATION OF MCH SERVICES AMONG WOMEN IN THE STUDY AREA Table 9: Factors associated with utilization of ANC among women in the study area Variables Kuchinbuyi χ2 Kilankwa χ2 (n=64) p value (n=55) p value Utilization of ANC Services Utilization of ANC Services Yes No Yes No N (%) N (%) N (%) N (%) Age groups (yrs) < 20 2 (25.0) 6 (75.0) 1 (25.0) 3 (75.0) 20-29 17 (70.8) 7 (29.2) 11.210* 12 (52.2) 11 (47.8) 8.729* 30-39 11 (55.0) 9 (45.0) 0.011 15 (78.9) 4 (21.1) 0.033 40 And Above 11 (91.7) 1 (8.3) 8 (88.9) 1 (11.1) Religion Christianity 30 (71.4) 12 (28.6) 2.880 21 (60.0) 14 (40.0) 1.266 Islam 11 (50.0) 11 (50.0) 0.090 15 (75.0) 5 (25.0) 0.260 Educational Level No formal Education 4 (40.0) 6 (60.0) 5 (45.5) 6 (54.5) Primary 13 (52.0) 12 (48.0) 8.910* 14 (63.6) 8 (36.4) 3.504* Secondary 18 (81.8) 4 (18.2) 0.031 12 (75.0) 4 (25.0) 0.320 Post-secondary 6 (85.7) 1 (14.3) 5 (83.3) 1 (16.7) 46 Occupation of Women Farming 15 (57.5) 11 (42.3) 13 (68.4) 6 (31.6) Unemployed/Housewife 4 (30.8) 9 (69.2) 13.782* 5 (35.7) 9 (64.3) 8.259* Self employed 14 (87.5) 2 (12.5) 0.003 11 (84.6) 2 (15.4) 0.041 Salaried employment 8 (88.9) 1 (11.1) 7 (77.8) 2 (22.2) Monthly Income (Women) Table 9 above shows the factors associated with utilization of ANC among women in the study area. In Kuchinbuyi, a slightly higher proportion of women aged 40 years and above (91.7%) utilized ANC services more than those in the other age groups and this was statistically significant, (LR=11.210, p=0.011). Also, a higher proportion of women who had post-secondary education (85.7%) utilized ANC more than women with other levels of education and the difference in proportions was statistically significant, (LR=8.910, p=0.031). Furthermore, a higher proportion of women who had salaried employment (88.9%) utilized ANC more than women in other occupational groups and the difference in proportions was statistically significant, (LR=13.782, p=0.003). Similarly, a higher proportion of women whose income was N30,000-N49,999 and those in N40,000 and above category (100%) utilized ANC more than women in other income categories and the difference was statistically significant, (LR=9.434, 47 p=0.024). On the other hand, a higher proportion of Christian women (71.4%) utilized ANC services more than Muslim women (50.0%), but the difference was not statistically significant. In Kilankwa, a higher proportion of women aged 40 years and above (88.9%) utilized ANC services more than those in the other age groups and the difference in proportions was statistically significant, (χ2=8.729, p=0.033). Also, a higher proportion of self-employed women (84.6%) utilized ANC more than women in other occupational groups and the difference in proportions was statistically significant, (LR=8.259, p=0.041). Similarly, a higher proportion of women whose income was N40,000 and above (100%) utilized ANC more than women in other income categories and the difference in proportions was statistically significant, (LR=10.440, p=0.015). On the other hand, a higher proportion of Muslim women (75.0%) utilized ANC services more than Christian women (60.0%), but the difference was not statistically significant. Similarly, a higher proportion of women who had post-secondary education (83.3%) utilized ANC services more than women with other levels of education, but the difference was not statistically significant. Table 10: Factors associated with utilization of delivery services among women in the study area Variables Kuchinbuyi χ2 Kilankwa χ2 (n=191) P value (n=194) p value Utilization of delivery Serv Utilization of Delivery Serv Yes No Yes No N (%) N (%) N (%) N (%) Age groups (yrs) < 20 7 (41.2) 10 (58.8) 5 (38.5) 8 (61.5) 20 – 29 36 (46.8) 41 (53.2) 2.050 48 (56.5) 37 (43.5) 1.789 30-39 27 (41.5) 38 (58.5) 0.562 34 (50.0) 34 (50.0) 0.617 40 And Above 18 (56.2) 14 (43.8) 14 (50.0) 14 (50.0) Tribe Gbagyi 36 (45.0) 44 (55.0) 0.590 55 (52.9) 49 (47.1) 0.213 Hausa/Fulani 22 (51.2) 21 (48.8) 0.745 18 (48.6) 19 (51.4) 0.889 Others 30 (44.1) 38 (55.9) 28 (52.8) 25 (47.2) Religion Christianity 52 (44.1) 66 (55.9) 0.500 56 (53.3) 49 (45.7) 0.148 Islam 36 (49.3) 37 (50.7) 0.480 45 (50.6) 44 (49.4) 0.700 Educational Level 48 No formal Education 15 (37.5) 25 (62.5) 23 (41.8) 32 (58.2) Primary 38 (46.9) 43 (53.1) 1.641 37 (51.4) 35 (48.6) 9.221 Secondary 28 (50.0) 28 (50.0) 0.650 31 (55.4) 25 (44.6) 0.026 Post-secondary 7 (50.0) 7 (50.8) 10 (90.0) 1 (9.1) Occupation of Women Farming 27 (40.3) 40 (59.7) 42 (50.6) 41 (49.4) Unemployed/Housewife 23 (46.9) 26 (53.1) 1.590 16 (35.6) 29 (64.4) 13.308 Self employed 28 (50.0) 28 (50.0) 0.662 33 (73.3) 12 (26.7) 0.004 Salaried employment 10 (52.6) 9 (47.4) 10 (47.6) 11 (52.4) Monthly Income (Women) Table 10 above shows the factors associated with utilization of delivery services among women in the study area. In Kuchinbuyi, a higher proportion of women aged 40 years and above (56.2%) utilized delivery services more than women in the other age groups, but the difference in proportions was not statistically significant. Also, higher proportion of Hausa/Fulani women (51.2%) utilized delivery services more than women in the other ethnic groups, but the difference was not statistically significant. Similarly, there was no statistically significant association between religion of women, their education, occupation, as well as their average monthly income, and their utilization of delivery services. 49 In Kilankwa, a slightly higher proportion of women aged 20-29 years (53.3%) utilized delivery services more than those in the other age groups, but the difference in proportions was not statistically significant. Also, a slightly higher proportion of Gbagyi women (52.9%) utilized delivery services than women in the other ethnic groups, but the difference was not statistically significant. Similarly, there was no statistically significant association between religion of the women, as well as their monthly income, and their utilization of delivery services. On the other hand, there was a statistically significant association between education of women and their utilization of delivery services. A higher proportion of women who had post-secondary education (90.9%) utilized delivery services more than women with other levels of education and difference in proportions was statistically significant, (χ2=9.221, p=0.026). Similarly, a higher proportion of women who were self-employed (68.9%) utilized delivery services more than women in the other occupational groups and the difference was statistically significant, (χ2=13.308, p=0.004). Table 11: Factors associated with utilization of post natal services among women in the study area Variables Kuchinbuyi χ2 Kilankwa χ2 (n=88) p value (n=101) p value Utilization of Post Natal Serv Utilization of Post Natal Serv Yes No Yes No N (%) N (%) N (%) N (%) Age groups (yrs) < 20 3 (42.9) 4 (57.1) 2 (40.0) 3 (60.0) 20 – 29 17 (47.2) 19 (52.8) 4.611* 20 (41.7) 28 (58.3) 3.431* 30-39 18 (66.7) 9 (33.3) 0.203 21 (61.8) 13 (38.2) 0.330 40 And Above 14 (77.8) 4 (22.2) 7 (50.0) 7 (50.0) Marital Status Married 48 (67.6) 23 (32.4) 6.040 41 (56.2) 32 (43.8) 4.672 Single 6 (35.3) 11 (64.7) 0.014 9 (32.1) 19 (67.9) 0.031 Educational Level No formal Education 6 (40.0) 9 (60.0) 9 (39.1) 14 (60.9) Primary 22 (57.9) 16 (42.1) 6.246* 16 (43.2) 21 (56.8) 5.665 Secondary 20 (71.4) 8 (28.6) 0.100 15 (53.6) 13 (46.4) 0.129 Post-secondary 6 (85.7) 1 (14.3) 10 (76.9) 3 (23.1) 50 Occupation of Women Farming 18 (66.7) 9 (33.3) 22 (52.4) 20 (47.6) Unemployed/Housewife 10 (43.5) 13 (56.3) 7.522* 4 (25.0) 12 (75.0) 5.947* Self employed 17 (60.7) 11 (39.3) 0.057 17 (51.5) 16 (48.5) 0.114 Salaried employment 9 (90.0) 1 (10.0) 7 (70.0) 3 (30.0) Monthly Income (Women) Table 11 above shows the factors associated with utilization of post natal services among women in the study area. In Kuchinbuyi, a slightly higher proportion of women aged 40 and above (77.8%) utilized post natal services more than women in the other age groups, but the difference in proportions was not statistically significant. Also, a higher proportion of women who had post-secondary education (85.7%) utilized post natal services more than women with other levels of education, but the difference was not statistically significant. Similarly, there was no statistically significant association between occupation of women and their utilization of post natal services. On the other hand, a higher proportion of married women (67.6%) utilized post natal services more than women who were single (35.3%) and the difference in proportions was statistically significant, 51 (χ2=6.040, p=0.014). Also, higher proportions of women whose income was N30,000-N49,999 and those in N40,000 and above category (100%) utilized ANC more than women in other income categories and the difference was statistically significant, (LR=8.959, p=0.030). In Kilankwa, higher proportion of women aged 30-39 years (61.8%) utilized post natal services more than women in the other age groups, but the difference in proportions was not statistically significant. Also, a higher proportion of women who had post-secondary education (76.9%) utilized post natal services more than women with other levels of education, but the difference was not statistically significant. Similarly, there was no statistically significant association between occupation of women, as well as their monthly income, and their utilization of post natal services. On the other hand, a higher proportion of married women (56.2%) utilized post natal services more than women who were single (32.1%) and the difference in proportions was statistically significant, (χ2=4.672, p=0.031). Table 12: Factors associated with utilization of family planning services among women in the area Variables Kuchinbuyi χ2 Kilankwa χ2 n = 200 n = 200 p value p value Utilization of Family Utilization of Family Planning Services Planning Services Yes No Yes No N (%) N (%) N (%) N (%) Age groups (yrs) < 20 7 (31.8) 15 (68.2) 3 (20.0) 12 (80.0) 20 – 29 35 (44.9) 43 (55.1) 6.422 33 (37.9) 55 (62.1) 7.117 30-39 32 (48.5) 34 (51.5) 0.093 37 (52.9) 33 (47.1) 0.068 40 And Above 22 (64.7) 12 (35.3) 11 (42.9) 16 (57.1) Marital Status Married 76 (48.1) 82 (51.9) 0.003 65 (43.6) 84 (56.4) 0.633 Single 20 (47.6) 22 (52.4) 0.965 19 (37.3) 32 (62.7) 0.426 Number of Living Children None 3 (42.9) 4 (57.1) 2 (40.0) 3 (60.0) 52 1-2 37 (49.3) 38 (50.7) 0.227* 24 (35.3) 44 (64.7) 6.026 3-4 34 (48.6) 36 (51.4) 0.973 34 (39.5) 52 (60.5) 0.110 5 and Above 22 (45.8) 26 (54.2) 24 (58.5) 17 (41.5) Religion Christianity 66 (53.2) 58 (46.8) 3.570 52 (47.7) 57 (52.3) 3.202 Islam 30 (39.5) 46 (60.5) 0.059 32 (35.2) 59 (64.8) 0.074 Educational Level No formal Education 19 (46.3) 22 (53.7) 23 (41.8) 32 (58.2) Primary 39 (47.0) 44 (53.0) 2.281 23 (31.9) 49 (68.1) 6.436 Secondary 28 (45.9) 33 (54.1) 0.516 28 (50.0) 28 (50.0) 0.092 Post-secondary 10 (6 6.7) 5 (33.3) 10 (58.8) 7 (41.2) Occupation of Women Farming 37 (50.7) 36 (49.3) 2.270 34 (40.0) 51 (60.0) 8.749 Unemployed/Housewife 20 (39.2) 31 (60.8) 0.518 19 (40.4) 28 (59.6) 0.033 Self employed 28 (50.0) 28 (50.0) 15 (33.3) 30 (66.7) Salaried employment 11 (55.0) 9 (11.0) 16 (69.6) 7 (30.4) *Likelihood Ratio (LR) Table 12 above shows the factors associated with utilization of family planning services among women in the study area. In Kuchinbuyi, a higher proportion of women aged 40 years and above (64.7%) utilized family planning services more than women in other age groups, but the difference in proportions was not statistically significant. Also, a slightly higher proportion of married women (48.1%) utilized family planning services more than women who were single (47.6%), but the difference in proportions was not statistically significant. Similarly, there was no statistically significant association between their number of living children, religion, educational level, as well as occupation, and their utilization of family planning services. 53 In Kilankwa, a higher proportion of women aged 30-39 years (52.9%) utilized family planning services than women in other age groups, but the difference in proportions was not statistically significant. Also, a higher proportion of married women (43.6%) utilized family planning services more than women who were single (37.3%), but the difference in proportions was not statistically significant. Similarly, there was no statistically significant association between their religion, number of living children, as well as their educational status, and their utilization of family planning services. On the other hand, a higher proportion of women who had salaried employment (69.6%) utilized family planning services than women in other occupational groups and the difference was statistically significant, (χ2=8.749, p=0.033). Table 13: Factors associated with utilization of child OPD services among women in the study area Variables Kuchinbuyi χ2 Kilankwa χ2 (n=193) p value (n=195) p value Utilization of Child OPD Utilization of Child OPD Yes No Yes No N (%) N (%) N (%) N (%) Marital Status Married 88 (58.3) 63 (41.7) 0.916 100 (68.0) 47 (32.0) 12.309 Single 21 (50.0) 21 (50.0) 0.339 19 (39.6) 29 (60.4) <0.001 Educational Level No formal Education 22 (53.7) 19 (46.3) 29 (53.7) 25 (46.3) Primary 41 (50.6) 40 (49.4) 6.366 43 (60.6) 28 (39.4) 5.939 Secondary 34 (59.6) 23 (40.4) 0.095 33 (61.1) 21 (38.9) 0.115 Post-secondary 12 (85.7) 2 (62.5) 14 (87.5) 2 (12.5) Occupation of Women Farming 37 (52.1) 34 (47.9) 47 (56.0) 37 (44.0) Unemployed/Housewife 21 (43.8) 27 (56.2) 9.419 23 (51.1) 22 (48.9) 7.665 54 Self employed 36 (65.5) 19 (34.5) 0.024 33 (73.3) 12 (26.7) 0.053 Salaried employment 15 (78.9) 4 (21.1) 16 (76.2) 5 (23.8) Monthly Income (Women) Occupation of Husband n = 158 n = 149 Farming 42 (53.2) 37 (46.8) 47 (65.3) 25 (34.7) Unemployed 5 (55.6) 4 (44.4) 2.386* 4 (44.4) 5 (55.6) 4.222* Self employed 31 (59.6) 21 (40.4) 0.496 34 (77.3) 10 (22.7) 0.233 Salaried employment 13 (72.2) 5 (27.8) 16 (66.7) 8 (33.3) *Likelihood Ratio (LR) Table 13 above shows the factors associated with utilization of child OPD services among women in the study area. In Kuchinbuyi, a higher proportion of married women (58.3%) utilized child OPD services than women who were single (50.0%), but the difference in proportions was not statistically significant. Also, a higher proportion of women who had post-secondary education (85.7%) utilized child OPD services than women with other levels of education, but the difference in proportions was not statistically significant. Similarly, there was no statistically significant association between their monthly income, as well as their husbands’ occupation, and their utilization of child OPD services. 55 On the other hand, there was statistically significant association between occupation of women and their utilization of child OPD services. A significantly higher proportion of women who had salaried employment (78.9%) utilized child OPD services than women in other occupational groups, (χ2=9.419, p=0.024). In Kilankwa, a higher proportion of married women (68.0%) utilized child OPD services than women who were single and the difference in proportions was statistically significant, (χ2=12.309, p<0.001). On the other hand, a higher proportion of women who had post-secondary education (87.5%) utilized child OPD services than women in other groups, but the difference was not statistically significant. Similarly, there was no statistically significant association between occupation of women, their monthly income, as well as their husband’s occupation, and their utilization of child OPD services. Table 14: Factors associated with utilization of immunization services by children of women in the study area Variables Kuchinbuyi χ2 Kilankwa χ2 (n=68) p value (n=75) p value Utilization of Immunization Utilization of Immunization Services Services Yes No Yes No N (%) N (%) N (%) N (%) Age groups (yrs) < 20 3 (33.3) 6 (66.7) 3 (60.0) 2 (40.0) 20 – 29 14 (50.0) 14 (50.0) 2.456* 23 (63.9) 13 (36.1) 0.064* 30-39 13 (54.2) 11 (45.8) 0.483 16 (65.4) 9 (34.6) 0.996 40 And Above 5 (71.4) 2 (28.6) 6 (62.5) 3 (37.5) Marital Status Married 29 (51.8) 27 (48.2) 0.013 37 (65.4) 22 (34.6) 0.199 Single 6 (50.0) 6 (50.0) 0.911 11 (60.0) 5 (40.0) 0.655 Religion 56 Christianity 25 (56.8) 19 (43.2) 1.427 27 (73.0) 10 (27.0) 2.552 Islam 10 (41.7) 14 (58.3) 0.232 21 (55.3) 17 (44.7) 0.110 Educational Level No formal Education 6 (37.5) 10 (62.5) 13 (65.0) 7 (35.0) Primary 16 (51.6) 15 (48.4) 2.563* 17 (60.7) 11 (39.3) 0.321* Secondary 10 (58.8) 7 (41.2) 0.464 13 (65.0) 7 (35.0) 0.956 Post-secondary 3 (75.0) 1 (25.0) 5 (71.4) 2 (28.8) Occupation of Women Farming 13 (50.0) 13 (50.0) 21 (61.8) 13 (38.2) Unemployed/Housewife 8 (42.1) 11 (57.9) 2.567* 11 (61.1) 7 (38.9) 0.629* Self employed 10 (55.6) 8 (44.4) 0.463 10 (66.7) 5 (33.3) 0.890 Salaried employment 4 (80.0) 1 (20.0) 6 (75.0) 2 (25.0) *Likelihood Ratio (LR) Table 14 above shows the factors associated with utilization of immunization services by children of women in the study area. In Kuchinbuyi, a higher proportion of women aged 40 years and above (71.4%) utilized immunization services than women in other age groups, but the difference in proportions was not statistically significant. Also, a slightly higher proportion of married women (51.8%) utilized immunization services than women who were single (50.0%), but the difference was not statistically significant. Similarly, there was no statistically significant association between religion 57 of women, their education, as well as their occupation, and their utilization of immunization services. In Kilankwa, a higher proportion of women aged 30-39 years (65.4%) utilized immunization services than women in other age groups, but the difference in proportions was not statistically significant. Also, a slightly higher proportion of married women (65.4%) utilized immunization services than women who were single (60.0%), but the difference was not statistically significant. Similarly, there was no statistically significant association between religion of women, their education, as well as their occupation, and their utilization of immunization services. 4.5 PREDICTORS OF UTILIZATION OF MCH SERVICES AMONG WOMEN IN THE STUDY AREA Table 15: Predictor of utilization of delivery services among women in Kuchinbuyi Variable Odds ratio p value 95% Confidence interval for Odds ratio Lower Upper Tribe 0.051 Gbagyi 3.617 0.234 0.436 29.996 Hausa/Fulani 0.151 0.104 0.015 1.475 Others 1 Religion Christianity 0.458 0.465 0.056 3.721 58 Islam 1 Occupation 0.605 Farming 0.501 0.650 0.025 9.906 Unemployed/Housewife 0.222 0.340 0.010 4.907 Self-Employed 1.038 0.984 0.024 44.479 Salaried Employment 1 In Kuchinbuyi, ethnicity, religion and occupation of women did not show significant association with utilization of delivery services after regression. Hausa/Fulani women had the least odds for utilization of delivery services and were six times less likely to utilize delivery services than women in the other ethnic group, but this was not statistically significant. Also, Christian women had the highest odds for utilization of delivery services and were twice less likely to utilize delivery services than Muslim women, but this was statistically significant. Similarly, farmers had the least odds for utilization of delivery services and were about twice less likely to utilize delivery services than those who had salaried employment, but this was not statistically significant. Table 16: Predictors of utilization of post natal services among women in Kilankwa Variables Odds ratio p value 95% Confidence interval for Odds ratio Lower Upper Marital Status Married 7.065 0.082 0.780 64.034 Single 1 Educational Level 0.409 No formal Education 0.073 0.160 0.002 2.804 Primary 0.098 0.158 0.004 2.470 Secondary 1.361 0.869 0.035 53.559 Post-Secondary 1 59 Occupation 0.182 Farming 6.266 0.401 0.020 53.281 Unemployed/Housewife 0.229 0.523 0.012 21.047 Self-Employed 0.577 0.807 0.041 61.403 Salaried Employment 1 In Kilankwa, marital status of women, level of education and occupation of women did not show significant association with utilization of post natal services after regression. Married women had the highest odds for utilization of post natal services and were seven times more likely to utilize post natal services than women who were single, but this was not statistically significant. Also, women who had no formal education had the least odds for utilization of post natal services and were thirteen times less likely to utilize post natal services than women who had post-secondary education, but this was not statistically significant. Similarly, unemployed/housewives women had the least odds for utilization of post natal services and were four times less likely to utilize post natal services than women who had salaried employment, but this was not statistically significant. Table 17: Predictors of utilization of family planning services among women in Kuchinbuyi Variables Odds ratio p value 95% Confidence interval for Odds ratio Lower Upper Age Group (Yrs) 0.044 <20 0.165 0.038 0.030 0.906 20 – 29 0.167 0.020 0.037 0.751 30 – 39 0.247 0.070 0.054 1.121 40 And Above 1 Marital Status Married 2.270 0.159 0.726 7.097 Single 1 60 Number of living children 0.397 None 0.179 0.190 0.014 2.343 1-2 0.419 0.160 0.125 1.411 3-4 0.493 0.255 0.146 1.664 5 and Above 1 Religion Christianity 2.304 0.071 0.930 5.712 Islam 1 Occupation 0.275 Farming 0.202 0.180 0.019 2.096 Unemployed/Housewife 0.127 0.083 0.012 1.306 Self-Employed 0.278 0.287 0.026 2.938 Salaried Employment 1 In Kuchinbuyi, age group of women showed significant association with utilization of family planning services after regression. Women aged 20-29 years had the highest odds for utilization of family planning services and were six times more likely to utilize family planning services than those aged 40 years and above and this was statistically significant, (OR: 0.165; 95% CI: 0.030 - 0.906), p=0.038. On the other hand, marital status, number of living children, religion and occupation of women did not showed significant association with utilization of family planning services after regression. Table 18: Predictors of utilization of family planning services among women in Kilankwa Variables Odds ratio p value 95% Confidence interval for Odds ratio Lower Upper Marital Status Married 2.463 0.120 0.791 7.671 Single 1 Number of living children 0.027 None 0.099 0.016 0.006 1.773 1-2 0.124 0.003 0.232 0.490 3-4 0.236 0.030 0.265 0.870 5 and Above 1 61 Religion Christianity 2.299 0.069 0.938 5.637 Islam 1 Educational Level 0.033 No formal Education 0.178 0.037 0.023 1.365 Primary 0.253 0.170 0.036 1.800 Secondary 0.895 0.912 0.124 6.443 Post-Secondary 1 In Kilankwa, number of living children and education of women showed significant association with utilization of family planning services after regression. Women who had no living children had the least odds for utilization of family planning services and were ten times less likely to utilize family planning services than those who had five children and above and this was statistically significant, (OR: 0.099; 95% CI: 0.006 - 1.773), p=0.016. Similarly, women who had no formal education had the least odds for utilization of family planning services and were six times less likely to utilize family planning services than those who had post- secondary education and this was statistically significant, (OR: 0.178; 95% CI: 0.023-1.365), p=0.037. On the other hand, marital status and religion of women did not showed significant association with utilization of family planning services after regression. Table 19: Predictors of utilization of immunization services by children of women in Kuchinbuyi Variables Odds ratio p value 95% Confidence interval for Odds ratio Lower Upper Marital Status Married 0.711 0.763 0.053 55.707 Single 1 Religion Christianity 2.114 0.657 0.78 57.333 Islam 1 62 In Kuchinbuyi, marital status and religion of women did not show significant association with utilization of childhood immunization services after regression. Married women had the least odds for utilization of immunization services and were one and half times less likely to utilize childhood immunization services than women who were single, but this was not statistically significant. Similarly, Christian women had the highest odds for utilization of childhood immunization services and were twice more likely to utilize childhood immunization services than Muslim women, but this was not statistically significant CHAPTER FIVE DISCUSSION The women in the two study groups were similar in their age groups, marital status, religion, ethnic group composition, number of living children, educational status, occupation and their husbands’ occupation. This is similar to findings from a related study in Burkina Faso where two groups of women who received health promotion interventions shared similar socio-demographic 63 characteristics.76 Majority of the women were aged 20-29 years, with mean age of 30.1±8.4 years in Kuchinbuyi and 30.2±7 years in Kilankwa, and majority of them were married. This is expected in northern Nigeria where early marriage is very prevalent and agrees with similar studies in Nigeria where majority of women shared similar age groups and were married.77-78 The mean age of the women however differ from that found in a study in Ethiopia where the mean age of women was 26.8±6.3 years.79 Majority of women in the two groups were from Gbagyi ethnic group and Christians. This could be explained by the fact that the Gbagyi tribe, which is the major indigenous ethnic group in the FCT, and other minority ethnic groups located within the middle belt region of Nigeria are known to be mainly Christians. Similar studies among women in Nigeria had recorded that majority of women who attended ANC were Christians.78,80 However, there was a statistically significant difference in the average monthly income of women in the two groups as higher proportion of women (but more in Kuchinbuyi) make less than N10,000. This was followed by those who make between N10,000 to N29,9999, but more in Kilankwa. This could be attributable to the fact that a slightly higher proportion of women in Kuchinbuyi were unemployed/housewives, while slightly higher proportion of women in Kilankwa had salaried employment. The implication of the lower income levels among women in Kuchinbuyi is that they will be less likely to have financial access to use of health services. This was demonstrated in the Philippines where pregnant women who had professional or white collar jobs were significantly more likely than those not employed to have prenatal care and to adopt a contraceptive method after childbirth.48 Another study in Nigeria further showed that introduction of free maternal and child health care caused tremendous increases in the uptakes of antenatal booking and hospital delivery, underscoring the how financial restrictions could affect utilization of healthcare services.56 64 A higher proportion of women in both study groups owned cheaper home items such as kerosene lantern/stove, radio/television, and motor cycle; while few owned expensive items such as cars, gas cooker, fridge/freezers. This agrees with findings from Nigeria’s successive Demographic and Health Surveys (NDHS) where poverty rate was documented to be higher in the rural areas.22,81 Women in the two study groups had very good perception of MCH services and no significant difference was observed in their perception of ante natal care, facility delivery and immunization services. The implication is that the women will be more receptive to interventional services targeted towards promotion of MCH services. Two related studies in Kenya reported good perception of MCH services among men and women and a very strong association between women’s perception of access to and quality of care, and facility delivery.64-65 A similar study in Malawi also revealed that women’s perception of postnatal care and their knowledge of maternal morbidity and mortality play a vital role in uptake of postnatal care.63 High satisfaction rate for utilization of MCH services was also recorded among women in the study area as higher proportion of them were satisfied compared with proportion of those who were dissatisfied. This is similar to findings from a survey in south eastern Nigeria which showed that majority of women rated MCH services good in available public health facilities, with 89% of them willing to pay for health services if drugs were available.66 Utilization of ANC services was relatively high and comparable in the two study groups (64.1% and 65.5% respectively). The figures compare well with national figures of 60.6% and the north central figure of 67% recorded in the Nigeria’s 2013 NDHS, and much better than the national figure of 46.5% for rural areas.81 It is noteworthy that a significantly higher proportion of women in Kuchinbuyi did not register for ANC until after 4-5 months of pregnancy. This is close to findings from a previous study in a small Nigerian community where women did not register for ante natal care until their sixth month of pregnancy or later.58 This may prevent pregnant women in the 65 community from getting full benefits of ANC, including health education, complete immunization, haematinics, malaria prophylaxis, etc, which may impart negatively on pregnancy outcomes. It could be noted that some cultures in northern part of Nigeria does not permit women to go to the health facility when sick or pregnant without the permission of their spouses. Such traditions can affect uptake of ANC services even when the women are knowledgeable. Poverty and ignorance may also prevent women from booking early for ANC when pregnant. In recent times, the free maternal and child health care services provided by the SURE-P and the Federal Capital Territory Administration for selected primary and secondary health care facilities went a long way to provide greater access to MCH services to rural women and children in FCT. This study however recorded that major reasons why some women in both study groups did not go for ANC were lack of proper advice and lack of financial resources. It is therefore expected that sustainable health promotional interventions could address the low awareness recorded among the women and also stimulate them to register early for ANC. A study on health benefits of social mobilization in two districts of Peru and Honduras recorded a 25% increase among mothers who received four or more prenatal check-ups after the intervention.82 Institutional delivery in Nigeria has remained low despite increase in ANC attendance. In this study, the percentage of hospital deliveries recorded among women in the two study groups (46.1% vs. 52.1%) were reasonably better than 35.8% facility deliveries reported in Nigeria’s 2013 NDHS.81 Higher proportion of non-institutional deliveries among the women took place at home in the two study groups and the major cause was influence of friends and family members, followed by lack of money and far location of health facilities from their homes. Another reason may be the problem of cultural believes in some parts of Nigeria where home delivery is encouraged and acceptable for the ‘super women’, while facility delivery is reserved for the weak ones. Home deliveries and other kinds of non-institutional deliveries continue to pose great danger to the lives of millions of women in Nigeria. It is therefore desirable to introduce innovative programmes that will motivate women to 66 go to recognized health facilities to deliver their babies so as to reduce the number of deaths encountered in the process. A previous study in Lagos, south west Nigeria recorded that about 51.4% of women delivered outside health facilities.56 Similar qualitative study in Uganda also noted that though most women usually go to the health units at least once to attend antenatal care, few deliver at the health units.83 The commonly cited reasons were distance, negligence by husbands, easy accessibility to TBAs, and cultural practices. Women empowerment through education and public enlightenment will also be needed to address these barriers to utilization of MCH services recorded among them. Utilization of post natal services was high in both study groups, though slightly higher in Kuchinbuyi than in Kilankwa. This may be a reflection of the better perception of post natal services recorded among women in Kuchinbuyi. These figures were however higher than 4.9% reported in a similar study in Nigerian and 39.6% recorded in Nigeria’s 2013 NDHS,.44,81 It is therefore necessary to sustain the relatively higher rates recorded in this study through sustainable health promotional programmes. Utilization of family planning services was relatively low among women in the two study groups, and their major reason for non-use of family planning methods were influence of their husbands or religion, and fear from previous experiences. Non-use of family planning methods by a greater population of women will result in high rate of unregulated pregnancies which could endanger the life of women and that of their children, in addition to the attendant social problems from population explosion. The need to develop more innovative strategies to address the identified socio-cultural factors that limit use of family planning methods among women therefore cannot be overemphasized. Related African studies had identified demographic and socio-cultural factors as major determinants of use of family planning among women.45,84 67 No significant difference was found in the utilization of child OPD and immunization services among women in the two study groups, though higher proportions were recorded in Kilankwa community. This could be explained by the fact that women who brought their children for immunization are more likely to also bring them to the hospital when they get sick. The major factors that influenced women’s choice of facilities for child health services were affordability of care and attitude health workers at the facilities. There is no doubt that finance is an important factor in determining access to quality health services, particularly to women and children. Studies in Nigeria and Turkey had recorded that introduction of free maternal and child health care resulted in tremendous increases in the uptake of targeted MCH services.55,85 Another Nigerian study reported that despite the presence of functioning government maternity centre that offered full range of services; delivery fees, cultural beliefs and poor education prevented the women from accessing the services.58 The Federal Capital Territory health authority introduced free maternity and under-five health services to selected primary and secondary health facilities in the territory to minimize the financial barrier to access to MCH services. Perhaps, there may be the need to expand the intervention to other facilities, especially those in the rural areas, in addition to providing further training for health worker to improve their attitude and approach to work. Among women in Kuchinbuyi, age group, education, occupation, income, marital status, religion and number of living children were significantly associated with utilization of MCH services. While in Kilankwa, education, occupation, age group, income and number of living children were significantly associated with utilization of MCH services. These are similar to findings from previous studies which showed that socio-demographic factors were significantly associated with utilization of MCH services.17-19,45-46 The importance is that health education and other socio- economic interventions should be directed more at specific areas to improve the population’s attitude and utilization of MCH services. 68 CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS 6.1 CONCLUSIONS This study showed that women in the two study groups had good and comparable perception of maternal and child healthcare services. 69 Variable and comparable levels of utilization of MCH services were also recorded among women in the two study groups; these include the use of ante natal, delivery, post natal, family planning and child healthcare services. A number of factors were significantly associated with utilization of MCH services among women in the study area before and after the intervention. 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The socioeconomic determinants of maternal health care utilization in Turkey. Social Science and Medicine. 2000;50:1797-1806. APPENDIX 1 PARTICIPANT INFORMATION SHEET STUDY TITLE: Effect of community mobilization on utilization of maternal and child healthcare services in a rural community in the Federal Capital Territory, Abuja, Nigeria. 1. Introduction: My name is Dr. Sabastine Ndubisi Esomonu from Department of Community, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu. I want to carry out a research on effect of community mobilization on utilization of maternal and child healthcare services in a rural community in the Federal Capital Territory, Abuja, Nigeria. 84 2. Purpose of Research/Reason for selection: This research is for academic purpose only and you are being selected because you belong to the population of people who have been included for participation based on the design and selection criteria for the research. 3. Voluntariness: You have the freedom to choose whether or not to participate and your decision will not affect you in any way and you are also free to discontinue at any time. 4. Potential risk/discomforts: Some of the questions or topics may be sensitive or discomforting to you. However, you do not have to answer all the questions nor owe me any explanation for not answering them. 5. Benefits: You may benefit from some of the topics and/or questions that may be raised from the questionnaire. Your contribution(s) and outcome of the research may also assist the FCT health authority in better planning and improvement of healthcare services in relation to utilization of maternal and child healthcare services. 6. Confidentiality: Your personal identity will not be required for this study, while your responses and information will be kept private and used strictly for the purposes of this research. 7. Who to contact: I am willing to answer your questions right away, but if you have any question later, please feel free to contact me as follows; Dr. Sabastine N. Esomonu at Department of Community medicine, UNTH, Enugu. Telephone: 08031374350. APPENDIX 2 INFORMED CONSENT FORM I, ______have been invited to participate in a study on effect of community mobilization on utilization of maternal and child healthcare services in a rural community in the Federal Capital Territory, Abuja, Nigeria. I have read the foregoing information, or it has been read to me. I have had the opportunity to ask questions about it and the questions have been answered to my satisfaction. I consent voluntarily to be a participant in this study. 85 Print Name of Participant______ Signature of Participant______Date ______ If participant cannot read in English; I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Print name of witness______ (Selected by participant) Signature of witness ______ Date______Thumb print of participant APPENDIX 3 QUESTIONNAIRE FOR THE WOMEN Area code ------S/no ------Dear respondent, my name is Dr. Sabastine Ndubisi Esomonu of University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu. I am carrying out a study on utilization of maternal and child healthcare services among women in rural communities in of Federal Capital Territory, Abuja. The information provided in this questionnaire is for research purpose only and will be treated 86 confidentially. Your participation in the study is voluntary and your personal identity is not required. You can choose more than one options where necessary in the questions outlined below. SECTION 1: SOCIO DEMOGRAPHIC CHARACTERISTICS 1. How old were you? (yrs)...... 2. What is your marital status: (a) Married [ ] (b) Separated [ ] (c) Widowed [ ] (d) Single [ ] 3. What is your highest level of education? (a) None [ ] (b) Primary [ ] (c) Secondary [ ] (d) Tertiary [ ] 4. What is your occupation?...... 5. What is your tribe?...... 6. What is your religion? 7. What is your average monthly income? (a) (c) N30,000- 49,999 [ ] (d) ≥50,000 [ ] 8. How many children do you have? ...... 9. What is your husband’s occupation?...... 11. Which of the following items do you have in your house? (a) TV [ ] (b) Car [ ] (c) Gas cooker [ ] (d) Radio [ ] (e) Fridge [ ] (f) Rechargeable lantern [ ] (g) Kerosene stove [ ] (h) Bicycle [ ] (i) Freezer [ ] (j) Motorcycle [ ] (k) Kerosene lantern [ ] SECTION 2: PERCEPTION OF WOMEN ON MCH SERVICES 1. Have you encountered any problem(s) accessing MCH services in health facilities in your community? (a) Yes [ ] (b) No [ ] 2. If yes, what was the problem(s)? (i) Absence of health workers (a) Yes [ ] (b) No [ ] (ii) Long waiting time (a) Yes [ ] (b) No [ ] (iii) Lack of basic equipment (a) Yes [ ] (b) No [ ] (iv) Wrong diagnosis (a) Yes [ ] (b) No [ ] (v) High cost of services (a) Yes [ ] (b) No [ ] (vi) Rudeness/verbal abuse from workers (a) Yes [ ] (b) No [ ] (ix) Others, specify...... 87 3. How important do you believe in utilization of ante natal by pregnant women? (a) Very important [ ] (b) Important [ ] (c) Not Important [ ] 4. How important do you believe in the use of family planning methods? (a) Very important [ ] (b) Important [ ] (c) Not Important [ ] 5. How important do you believe in the use of health facilities for delivery of children? (a) Very important [ ] (b) Important [ ] (c) Not Important [ ] 6. How important do you believe in utilization of postnatal care by women after delivery? (a) Very important [ ] (b) Important [ ] (c) Not Important [ ] 7. How important do you believe immunization is for the survival of children? (a) Very important [ ] (b) Important [ ] (c) Not Important [ ] 8. How would you rate your level of satisfaction with MCH services provided at health facilities in your community? (a) Very satisfied [ ] (b) Satisfied [ ] (c) Undecided [ ] (d) Dissatisfied [ ] (e) Very dissatisfied [ ] SECTION 3: UTILIZATION OF ANTENATAL/ DELIVERY/POSTNATAL SERVICES 12. Are you currently pregnant? (If no, move to question 17) (a) Yes [ ] (b) No [ ] 13. Have you registered for ANC in a health facility for this pregnancy? (If no move to question 16) (a) Yes [ ] (b) No [ ] 14. If yes, at what stage of pregnancy did you register for ANC in this pregnancy? ...... 15. How many times have you attended ANC in this pregnancy? (a) Once [ ] (b) Two [ ] (c) Three [ ] (d) ≥ Four [ ] 88 16. If you are pregnant and not registered for ANC, what is your reason(s)? (i) I don’t believe it is necessary (a) Yes [ ] (b) No [ ] (ii) I don’t have money (a) Yes [ ] (b) No (iii) Health centre is far (a) Yes [ ] (b) No [ ] (iv) It is against my religion (a) Yes [ ] (b) No [ ] (v) It is against our culture (a) Yes [ ] (b) No [ ] (vi) No body advised me (a) Yes [ ] (b) No [ ] 17. Did you deliver your last child in a health facility? (If no, move to question 20) (a) Yes [ ] (b) No [ ] 18. If yes, did you go back for Post Natal Care (PNC)? (a) Yes [ ] (b) No [ ] 19. If no to question 18 above, why? (i) I was not told to come back (a) Yes [ ] (b) No [ ] (iii) I didn’t think it was necessary (a) Yes [ ] (b) No [ ] (iv) Distance (a) Yes [ ] (b) No [ ] (v) Influence of family members (a) Yes [ ] (b) No [ ] (vi) No reason (a) Yes [ ] (b) No [ ] (vii) Others: ...... 20. If you did not deliver your last in a health facility, where did you have the delivery? (a) TBA [ ] (b) At home [ ] (c) Religious home [ ] (d) Chemist shop [ ] (e) Other, specify...... 21. If you did not deliver in the health facility, what was your reason? (a) Cost of treatment [ ] (b) Influence of friends/family members [ ] (c) Health centre was too far [ ] (d) Health centre was closed [ ] (e) Not sure of the quality of care at health centre [ ] (f) Other...... 22. How often did you receive health education at health facilities? (a) Always [ ] (b) Occasionally [ ] (c) Never [ ] SECTION 4: UTILIZATION OF FAMILY PLANNING SERVICES 89 23. What family planning method do you know? (i) Condoms (a) Yes [ ] (b) No [ ] (ii) Oral contraceptives (a) Yes [ ] (b) No [ ] (iii) Billings method (a) Yes [ ] (b) No [ ] (iv) Exclusive breastfeeding (a) Yes [ ] (b) No [ ] (v) Injectables (a) Yes [ ] (b) No [ ] (vi) Tubal ligation (a) Yes [ ] (b) No [ ] (vii) Vasectomy (a) Yes [ ] (b) No [ ] (viii) Implants (a) Yes [ ] (b) No [ ] (ix) IUCD Yes [ ] (b) No [ ] 24. Are you currently using any family planning method? (If no, move question 31) (a) Yes [ ] (b) No [ ] 25. If yes, which one are you using? (a) Oral pills [ ] (b) Condoms [ ] (c) Injectables [ ] (d) Billings method [ ] (f) Exclusive breastfeeding [ ] (g) Other,...... 26. Why did you prefer the one you are using? (i) Availability (a) Yes [ ] (b) No [ ] (ii) It has minimal risk/side effects (a) Yes [ ] (b) No [ ] (iii) It is cheap (a) Yes [ ] (b) No [ ] (iv) It is easy to use (a) Yes [ ] (b) No [ ] (v) Other, specify...... 27. Where did you receive the service? (a) Health centre [ ] (b) TBA/Chemist shop [ ] (c) Private hospital [ ] (d) Others, ...... 28. How did you learn about the method you are using? (i) From friends/family members (a) Yes [ ] (b) No [ ] (ii) From Radio/TV (a) Yes [ ] (b) No [ ] (iii) From health personnel (a) Yes [ ] (b) No [ ] (iv) From women’s forum (a) Yes [ ] (b) No [ ] (v) From religious groups (a) Yes [ ] (b) No [ ] (vi) Other, specify ...... 29. If you are not using any family planning method now, why? (i) High cost of the services (a) Yes [ ] (b) No [ ] (ii) I am not aware it exist (a) Yes [ ] (b) No [ ] 90 (iii) My husband did not approve it (a) Yes [ ] (b) No [ ] (iv) I am afraid/previous experience (a) Yes [ ] (b) No [ ] (v) No reason (a) Yes [ ] (b) No [ ] (vi) My religion does not approve it (a) Yes [ ] (b) No [ ] (vii) Others, specify...... 30. Have you had any bad experience with any family planning method? (a) Yes [ ] (b) No [ ] 31. If yes, what was your experience? (i) Non-menstrual bleedings [ ] (ii) Stoppage of menses [ ] (iii) Heavy menstrual flow [ ] (iv) Fever [ ] (v) Unusual vaginal discharge [ ] (vi) Weight gain [ ] (vii) Delayed fertility [ ] (viii) Unexpected pregnancy (a) Yes [ ] (b) No [ ] (ix) Abdominal pain (a) Yes [ ] (b) No [ ] (x) Unpleasant/painful sexual intercourse [ ] (xi) Others, specify…...… 32. After your experience, what did you do? (a) I stopped to use it [ ] (b) I continued to use it [ ] (c) I consulted health personnel [ ] (d) I complained to my husband [ ] (e) Other, specify...... SECTION 5: UTILIZATION OF CHILD OPD/IMMUNIZATION SERVICES . 33. When your child (children) fall sick, where do you usually take them to? (i) Govt. health centre (a) Yes [ ] (b) No [ ] (ii) Private clinic (a) Yes [ ] (b) No [ ] (iii) Traditional healers (a) Yes [ ] (b) No [ ] (iv) Chemists (a) Yes [ ] (b) No [ ] (v) Church/Mosque (a) Yes [ ] (b) No [ ] (vi) I don’t have any child (a) Yes [ ] (b) No [ ] (vii) Other, specify...... 34. What is your reason for your choice of treatment method above? (i) Influence of family/friends (a) Yes [ ] (b) No [ ] (ii) Affordability (a) Yes [ ] (b) No [ ] 91 (iii) My belief in their practice (a) Yes [ ] (b) No [ ] (iv) Nearness to my house (a) Yes [ ] (b) No (v) Caring attitude of their staff (a) Yes [ ] (b) No [ ] (vi) Advice from health personnel (a) Yes [ ] (b) No [ ] (vii) Other, specify...... 35. Are all your children <5 years fully immunized? (a) Yes [ ] (b) No [ ] (c) Not Applicable [ ] 36. If No, what are your reason(s)? (i) No time to go to health centre (a) Yes [ ] (b) No [ ] (ii) Distance from my house (a) Yes [ ] (b) No [ ] (iii) I Don’t believe it works (a) Yes [ ] (b) No (iv) Drugs not always available at the health centre (a) Yes [ ] (b) No [ ] (v) I am not aware of it (a) Yes [ ] (b) No [ ] (vi) Husband didn’t approve it (a) Yes [ ] (b) No [ ] (vii) My Religion doesn’t approve it (a) Yes [ ] (b) No [ ] (viii) Child had a reaction in the past (a) Yes [ ] (b) No [ ] (ix) Other, specify...... Thank you for your time! 92 93 94 95