COMPARATIVE STUDY OF UTILIZATION OF MATERNAL AND CHILD
HEALTH SERVICES IN URBAN AND RURAL COMMUNITIES IN
ANAMBRA STATE.
BY
DR. BIBIANA NONYE EGENTI (MBBS) DEPARTMENT OF COMMUNITY MEDICINE NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL, NNEWI ANAMBRA STATE
A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE FELLOWSHIP IN PUBLIC HEALTH
NOVEMBER 2009
1 DECLARATION
I hereby declare that this study is original and that any assistance received is fully acknowledged.
I also declare that I have not previously submitted this dissertation in part or in full for any examination or publication.
------Dr. Bibiana Nonye Egenti Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State. NOVEMBER 2009
2 DEDICATION To my parents Chief Aloysius I. Obiagwu and Dr. Clara O. Obiagwu, who gave me the benefits of Western Education and to my husband Chike, and children Kene,
Uzo, Chigo and Ike for their love and encouragement throughout the period of my residency programme and this work in particular.
Thank you all for being there for me.
3 CERTIFICATION
We certify that we supervised this work carried out by Dr. Bibiana Nonye Egenti of the Department of Community Medicine, Nnamdi Azikiwe University Teaching
Hospital Nnewi, Anambra state.
------Prof. C. N. Obionu Dr. E. U. Ebenebe MBBS, FWACP, FMCPH MBBS, FMCPH
4 ACKNOWLEDGEMENT
I am particularly grateful to my supervisors Prof. C. N. Obionu and Dr. E. U.
Ebenebe who despite their busy schedule gave me purposeful guidance and support in making this work become a reality. I greatly appreciate Dr. B.S.C. Uzochukwu who has played a major role in the course of my training as a Public Health Physician. I wish to thank Drs.U.U. Onyeonoro, Chika Ubajaka and Prosper Adogu for their encouragement, support and constructive criticisms in the course of carrying out this work and in the final shaping of the work.
My profound gratitude goes to Prof. Chika Onwasigwe who helped with the statistical calculations and analysis. Uju Okeke deserves special mention for always being willing to type the manuscript whenever the need arose. I thank all the mothers of under fives in Nnewi North and Dunukofia Local Government Areas for the willingness and cooperation they exhibited in the course of my carrying out the study. My research assistants were quite commendable; particular thanks go especially to nurse educator;
Mrs. Oluchukwu Ifele who led the team.
Extra special thanks to my family; fantastic in every way. To my mother, Dr. C.
O. Obiagwu who patiently listen to my moans, read and corrected my work and also helped in gathering materials for the work.
Most especially, I am grateful to Almighty God for everything.
5 ABSTRACT
Introduction/Objective: Maternal and child health is an aspect of primary health care that seeks to promote both the health of the mother particularly through the child bearing period and also the health of the child. This study determined and compared the level and pattern of utilization of MCH services in urban and rural communities in
Anambra State and identified factors influencing them.
Design and Method: A comparative cross-sectional descriptive study was carried out in two Local Government Areas in Anambra State; Nnewi North (urban) and Dunukofia
(rural). The study was conducted between January-March 2009. A total of three hundred and thirty eight (338) mothers with children aged 0-59 months in each of the two LGAs selected by multistage cluster sampling technique were studied. Data was collected from them using a semi-structured, pre-tested, interviewer administered questionnaire. This was complemented with a 2 year retrospective review of public health facility records in the study communities on antenatal care, delivery services and postnatal care services utilization and routine immunization of children. SPSS version
13 software package was used for data analysis. The data collected was analyzed using statistical means, chi-Square test and percentages and the p-value was set at 0.05.
Results: Majority of the women were aged between 25–34 years of age, married and educated in both communities. However, women in the rural area had higher fertility rate (t=4.53, p<0.05) and more children alive (t=4.79,p<0.05) but the urban women were more educated and were of higher socioeconomic status. Knowledge of MCH
6 service utilization was high among the respondents although higher in the urban area.
Also, ANC, maternity and post natal services utilization rate was high in both communities but level and pattern of utilization differed in both localities. Majority in the urban areas utilized the services of the private hospitals while the majority of the rural women patronized the maternity homes and had less access to skilled birth attendants. Average ANC attendance and booking in the first trimester of the pregnancy were statistically significant in both areas (χ2 = 7.52, p < 0.05 and χ2 = 8.96, p < 0.05 respectively). Only 16% of women in the rural areas were involved in decision making of their health issues as against 12.1% of women in the urban areas. Physical and economic access, in addition to quality of service and family decision making process were the factors influencing MCH service utilization particularly in the rural women.
Also, health facility assessment also revealed low MCH service utilization in the rural than in urban area.
Conclusion: The study demonstrated obvious difference in maternal and child health care service utilization in both localities. Women in the rural communities were less likely to have access to quality MCH services, because they are less educated.
Therefore, measures to improve maternal and child health service utilization should not only address the issue of access to care, but also improvement in quality of care and women empowerment.
7 CONTENTS PAGE DECLARATION i DEDICATION ii CERTIFICATION iii ACKNOWLEDGEMENT iv ABSTRACT v-vi TABLE OF CONTENTS vii-viii LIST OF TABLES ix LIST OF FIGURES x LIST OF ACRONYMS xi-xii CHAPTER ONE: INTRODUCTION 1.1 Background of maternal and child health 1-4 1.2 Statement of problem 4-6 1.3 Scope of study 6 1.4 Justification of the study 6-7 1.5 Relevance of the study 8 1.6 Aims and objectives 9 1.6.1 General objective 9 1.6.2 Specific objectives 9 TWO: LITERATURE REVIEW 2.1 Maternal and child health, Primary Health Care and Millennium Development Goals 11-12 2.2 Components and indicators of MCH services 13-14 2.3 Pattern and level of MCH service utilization 14-18 2.4 Factors influencing utilization of MCH services 18-30
8 2.5 Urban-Rural differences 30-33 THREE: MATERIALS AND METHOD 3.1 Study areas 34 3.1.1 Nnewi North LGA 34-36 3.1.2 Dunukofia LGA 36 3.2 Study population 37 3.3 Study design 37 3.4 Sample size estimation 38 3.5 Inclusion criteria 39 3.6 Sampling Technique 39-40 3.7 Data collection 40-41 3.8 Data analysis 42 3.9 Pretest 43 3.10 Study schedule 44 3.11 Ethical consideration 45 3.12 Limitations 45 3.13 Definition of key variables 46 FOUR: RESULTS 4.1 Tables 1–19 47-71 4.2 Figure 1 72 4.3 Figure 2 73 4.4 Table 20 74 FIVE: DISCUSSION 5.1 Discussion 75-84 5.2 Conclusion 85 5.3 Recommendations 86-87 REFERENCES 88-94 APPENDICES 95-111
9
LIST OF TABLES
TABLE PAGE
1: Sociodemographic characteristics of respondents 47-49 2: Comparison of mean values of urban and rural dwellers 50 3: Household decision maker on health issues 51 4: Distance of nearest health facility from place of residence 52 5: Socioeconomic status and ownership of personal household items 53 6: Knowledge of mothers in utilization of MCH services 54 7: Perception of mothers in utilization of MCH services 55 8a: Utilization of MCH services regarding ANC 56 8b: Mean number of ANC visits before delivery 57 9: Reasons for non-attendance of ANC during last pregnancy 58 10: Utilization of maternity services among the respondents 59-60 11: Mothers reasons for not delivering in a health facility 61 12: Utilization of MCH services regarding postnatal care 62-63 13: Utilization of MCH services regarding immunization 64 14: Children’s completion of immunization 65 15: Mothers/caregivers reasons for non-completion of child’s immunization 66 16: Utilization of maternal health services in public health facilities 67-68 17: Proportion of deliveries and PNC visit in the public health facilities 69
18: Percentage DPT3 immunization coverage by wards in both communities 70 19: Percentage measles immunization coverage by wards in both communities 71 20: Dropout rate of immunization in the public health facilities for 2007-2008 74
10 LIST OF FIGURES
FIGURE PAGE
1: Graph showing percent DPT3 immunization coverage in urban
and rural areas 72
2: Graph showing percent measles immunization coverage in urban
and rural areas 73
11 LIST OF ACRONYMS
ANC Antenatal care
ARI Acute respiratory infection
BCG Bacillus calmette Guerin
BI Bamako initiative
CSM Cerebrospinal meningitis
DALY Disability adjusted life year
DHS Demographic health survey
DPT Diphtheria, pertussis, tetanus
HBV Hepatitis B virus
IMCI Integrated management of childhood illnesses
LGA Local government area
MCH Maternal and child health
MDG Millennium development goal
NDHS National demographic and health surveys
NFHS National family health survey
NID National immunization day
NICS National immunization coverage survey
NPC National population commission
NPI National programme on immunization
NW North west
12 OPV Oral polio vaccine
PHC Primary health care
PNC Postnatal care
PTF Petroleum trust fund
RI Routine immunization
SMOH State ministry of health
SSA SubSaharan Africa
SPSS Statistical package for social sciences
TB Tuberculosis
TBA Traditional birth attendant
UN United Nations
UNFPA United Nations Fund for Population Activities
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VPD Vaccine preventable disease
WHO World Health Organization
13 CHAPTER ONE
INTRODUCTION
1.1 Background of Maternal and Child Health (MCH)
The National Health Policy places a major emphasis on primary health care
(PHC) as the strategy for attaining health for all. Components of PHC include: health education on prevailing health problems; nutrition for all segments of the population; immunization; maternal and child health care; adequate and safe food supply and maintenance of water quality, supply and sanitation; environmental protection; treatment of minor ailments and injuries; provision of essential drugs and prevention and control of endemic diseases; mental and dental health. It is evident that maternal and child health (MCH) is an integral part of primary health care which is the global strategy for attaining health for all.
The goal of MCH seeks to address the high risks that women in many contexts face in relation to child bearing and the treatment and protection of children against some known childhood killer diseases. Components of MCH include maternal health, child health, family planning, adolescent health and school health. MCH programs emphasize the need for pregnant women to receive adequate prenatal care that protects them against the avoidable complications of pregnancy, and allows them to undergo a safe delivery, and to receive adequate postnatal care. There exists an association between maternal health and the health status of children, which can be measured in the form of a reduction in either mortality or risks to child survival1. Child health services
14 aim for the prevention of acute illness that will disrupt the child's development and childhood immunization is an important facet of MCH.
Maternal health services begin at the time of conception and include pre-natal, intra-natal and post-natal care. Pre-natal supervision of the mother promotes good health and proper nutrition of the mother. Also, complications of pregnancy are prevented or treated. Intra-natal services provide skilled care by trained midwives during childbirth, while post-natal care checks on the mother's health after delivery and these include family planning services. Postnatal care makes it possible for a health care provider to diagnose and prevent some of the chronic and disabling conditions common in women.
Various ways has been used to describe MCH services utilization. Yesudian described full antenatal care (ANC) utilization as three or more antenatal check-ups
(with the first checkup within the first trimester of pregnancy), two or more tetanus toxoid injections, and Iron and folic acid tablets or syrup for three or more months.2
Iraq’s Maternal, Child and Reproductive Health Strategy for 2005-2008 aimed at achieving antenatal care (ANC) utilization rate of at least five visits during pregnancy.3
ANC utilization can also be assessed using proportion of women who received ANC at least once during the last pregnancy.4,5
Percent of deliveries by skilled attendant is defined as proportion of births or deliveries attended by skilled health personnel or skilled attendant: doctors (specialist or non-specialist) and /or persons with midwifery skills who can diagnose and manage
15 obstetrical complications as well as normal deliveries. 6 Delivery in a health facility describes deliveries that took place in a facility either public or private. Post natal care
(PNC) utilization is measured based on proportion of mothers who visit the PHC centers at least once during the 6 weeks following delivery.2, 3
Immunization practices indicators include percent of children that received any childhood vaccine or percent that have received all the required doses of the various vaccines by 0–23 months. A child is said to be fully immunized/vaccinated if he/she has received all the vaccines as recommended in the national immunization schedule.
Antigen coverage rate is a measure of the percent of eligible children that have adequate doses of specific antigen.7 Dropout rates are calculated as the percentage point difference between successive doses of a vaccine, expressed as a percentage of the first dose: the dropout rate between the first and third dose of DPT is: (DPT1-DPT3)/DPT1.
Dropout rates may also be calculated as the difference between one vaccine and another
(i.e. BCG and DPT3).8
Literature for the status of access and use of health care in developing countries identifies cost, distance and education as the principal factors influencing utilization of health services. Low quality of care characterized by shortage of manpower, poor staff attitude, dissatisfaction with maternal services, long waiting hours and unavailability of drugs or vaccines have also been advanced as reasons for low utilization of healthcare.
Disparity in distribution of health resources between urban and rural communities to the
16 disadvantage of the latter, aggravated by low income, ignorance, poor infrastructure contributes significantly, to further reduce health services utilization in the rural areas. 9, 10
1.2 Statement of Problem
Every year nearly 500,000 women die of complications related to pregnancy and childbirth, and 99% percent of these deaths occur in developing countries. 11 Access to maternal and child health services in developing countries are low, consequently there is low utilization of MCH which has been linked to maternal and infant mortality and morbidity patterns. About 99% of the causes of maternal mortality in the developing countries are due to preventable complications of pregnancy and childbirth.10 Maternal death and disability are the leading causes of healthy life years lost for developing country women of reproductive age, accounting for more than 28 million disability- adjusted life years (DALYs) lost and at least 18% of the burden of disease in these women. For each woman who dies, an estimated hundred women survive childbearing but suffer from serious disease, disability, or physical damage caused by pregnancy- related complications. Long-term consequences of pregnancy-related complications include uterine prolapse, pelvic inflammatory disease, fistula, incontinence, infertility, and pain during sexual intercourse. In some developing countries, if the mother dies, the risk of death for her children under age five is doubled or tripled. In addition, because a woman dies during her most productive years, her death has a strong social and
17 economic impact on her family and community as a productive worker and a primary care giver.2
Nigeria has one of the highest maternal and infant mortality rates in the world and this necessitated the greater attention given to maternal and child health (MCH) services in the country's Bamako initiative (BI) programme.12 Nigeria is said to account for 10% of the world’s maternal mortality burden, one of the highest in the world, despite measures being taken to improve maternal health care. Maternal mortality ranges from 800 to over 1500 per 100,000 live births .13 Nigerian women run a risk of dying during pregnancy or childbirth that is 100 times greater than that faced by women in Western Europe. The lifetime risk of maternal death in Nigeria is 1 in 13 while for regions like Asia, Latin America and Europe it is 1 in 94, 1 in 160 and 1 in 2400 respectively.14 The unacceptably high maternal mortality and morbidity are due to a variety of reasons, including non-availability of services and poor utilization of maternal health services even when they are available.
Routine immunization against DPT, measles, polio and TB is proven to be one of the most cost-effective interventions for reducing childhood illnesses and mortality, especially with the addition of other vaccines such as cerebrospinal meningitis (CSM) and yellow fever vaccines in endemic areas and tetanus toxoid injections for pregnant women. International comparative data show that Nigeria’s immunization coverage rates are among the worst in the world. National coverage in Nigeria for full immunization was formerly less than 13%, one of the lowest rates in the world15 but
18 currently, the national immunization coverage for full immunization (using DPT3) is
54%.16 Some States in Northern Nigeria had coverage rates below 1%, and the average for the whole North West Zone was just 4%. Between the Demographic and Health surveys (DHS) for 1999 and 2003; one dose of the traditional vaccines (BCG, three doses of DPT and OPV, Measles) by their first birthday rose from 60.9% to 69.4%. Yet the percentage fully immunized with all doses before 12 months of age fell from 14.3% in 1999 to 11.3% in 2003, and drop-out between first and third dose of DPT increased from 45.7% to 48.1%, indicating growing problems with the continuity of routine immunization services.15
1.3 Scope of study
This study is restricted to the assessment of the following MCH services; utilization of antenatal care, delivery services, postnatal care and childhood immunization services.
1.4 Justification of the study
Despite significant advances in efforts aimed at reducing maternal mortality, the majority of women residing in disadvantaged communities still face multitudes of problems that need to be addressed. Policy Project, an implementing partner of USAID that specializes in child survival issues observed that, “in most developing countries, access to safe motherhood services in rural areas is more limited than in urban areas.”
19 This issue is important as majority of the population of developing countries live in rural areas.15
Mothers are the first and most important health care agent of their children and should be given the highest priority in any health care program. Thus, the importance of
MCH services (primarily health services) can never be over emphasized.1 Utilization of immunization services has been linked to maternal services utilization and some studies have shown disparity in the factors influencing urban and rural utilization of MCH services. So, it is believed that identifying factors influencing utilization will form the basis of evolving solution towards improved MCH services. This study is aimed at determining the extent of utilization of MCH services in an urban and rural community in Anambra State.
20 1.5 Relevance of the study
Understanding the barriers that prevent good quality MCH service provision and utilization of maternal care services can be useful in efforts to encourage women to utilize the services; planning for future efficient services that can help reduce maternal deaths, especially in rural areas; improving the health and lives of all women during and after pregnancy; developing appropriate community and behaviour change interventions in order to improve utilization of maternal care services; and the design of maternal health campaign services in the country. LGAs also, need more community-based information about the vaccination status of their population in order to define the priorities, determine the disadvantaged groups, and plan and implement interventions that aim to improve vaccination coverage in their localities. Findings will be used to improve community mobilization towards strengthening MCH services, improve PHC services, attainment of health for all and Millennium Development Goals (MDGs) 4 and 5.
21 AIMS AND OBJECTIVES
1.6.1 General objective
To determine and compare the level and pattern of utilization of MCH services among mothers of children aged between 0-59 months in urban and rural communities in Anambra State and the factors influencing it.
1.6.2 Specific Objectives
1. To determine the knowledge and perception of MCH services among mothers of
children aged 0 – 59 months in both urban and rural communities.
2. To determine the level and pattern of MCH utilization among the study
population.
3. To identify the factors influencing MCH utilization among the study population.
4. To compare the knowledge, perception and factors influencing MCH utilization
among the study population in both urban and rural communities.
22 CHAPTER TWO
LITERATURE REVIEW
2.1 Maternal and Child Health (MCH), Primary Health Care (PHC) and Millennium Development Goals (MDGs).
Following Alma Ata Declaration of 'Health for all by 2000 AD' through primary health care in 1978 and consequent upon its adoption by various countries, primary health care became the strategy for attainment of national health policies. This development led to accelerated development and strengthening of maternal and child health (MCH) programs with the provision of more health facilities in order to achieve the goal. Included in the Declaration’s aims was that by the year 2000 all people of the world would have obtained a sufficient level of health to permit socially and economically productive lives.1
International commitment to reducing maternal mortality was reaffirmed in
December 2000 when 149 government leaders from 191 United Nations member states committed themselves to achieving a set of Millennium Development Goals (MDGs), by 2015. Reducing maternal mortality by three-quarters from its 1990 level is one of these key goals. The maternal mortality ratio and the proportion of deliveries with a skilled attendant will be used to monitor progress towards this goal. In developing countries a woman's lifetime risk of dying from pregnancy-related complications is 45 times higher than that of her counterparts in developed countries. The risk of dying from pregnancy-related complications is highest in sub-Saharan Africa and in South-
23 Central Asia, where in some countries the maternal mortality ratios are more than 1,000 deaths per 100,000 live births.17
A 1998 report on “Confidential Enquiries into Maternal Deaths” in South Africa pointed at poor antenatal care attendance as one of the avoidable factors underlying maternal mortality. Likewise, Pattinson identified avoidable factors as major causes of maternal complications and death.18 Maternal health care is aimed at addressing identifiable preventable complications associated with pregnancy and child birth. It is therefore believed that improving access to quality maternal services and effective utilization of such services will significantly improve maternal health, reduce maternal deaths and promote attainment of millennium development goal 5.3
Immunization is regarded as one of the greatest medical success stories in human history and has saved millions of lives in the 20th century. Many serious childhood diseases are preventable by using vaccines routinely recommended for children. Since the introduction of these vaccines, rates of diseases such as polio, measles, mumps, rubella, diphtheria, pertussis and meningitis caused by haemophilus influenzae type b have declined from 95 to 100%. Prior to immunization, hundreds of thousands of children were infected and thousands died each year from these diseases. In under immunized populations of the world, 600,000 children die from pertussis and almost one million die from measles each year. Many of the children who survive could suffer from chronic health problems or disabilities for the rest of their lives. United States reported the biggest measles epidemic 1989-1991 which was due to failure to vaccinate
24 preschool children on time. This measles epidemic was responsible for 55,000 cases and more than 120 deaths and nearly half of those deaths were in children under age five.
In Nigeria, Vaccine Preventable Diseases (VPDs) currently account for about
22% of deaths for children aged under five.19 In 2002 deaths in Nigerian children aged
0-5 are estimated to have been 872,000; therefore, in that year UNICEF estimates that close to 200,000 Nigerian children died from VPDs.19 At least 17,000 Nigerian infants are estimated to have died in 2000 due to neonatal tetanus. Deaths from measles have been estimated at 96,000 per year.20 The northern part of Nigeria is prone to epidemics of CSM; in 1996 more than 75,000 cases of CSM were treated and 8,440 people died.
However, there is no figure for the adverse effect among the survivors. Most of these morbidity and mortality can be significantly reduced by improving maternal and child health services particularly routine immunization in the country. Such a measure is thought will impact positively on the nation’s aspiration of attaining millennium development goals 4 – to reduce child mortality. The target is to reduce by two-thirds between 1990 and 2015 the under five mortality rate. Indicators for monitoring the progress include among others; proportion of under 1-year old children immunized against measles.21
25 2.2 Components and Indicators of MCH services
Maternal and child health services are broadly divided into maternal and child health care. The maternal health care component comprise of family planning
(contraceptive services), abortion services, perinatal care and obstetric care which is further divided into routine and emergency obstetrics care. Routine obstetrics care comprises of ANC, delivery services and post natal care. During the ANC, records of her health history are taken, routine investigations carried out, ferrous sulphate and folic acid tablets given during each visit and at least two doses of tetanus toxoid given (if not previously vaccinated). Also, early risk factors in pregnancy are detected and treated.
Post natal care provides the women opportunity to receive physical examination, ferrous sulphate if anaemic, Vitamin A and counseling on breast-feeding and family planning. Complications of childbirth are detected and treated.3 Indicators for assessing maternal care include ANC utilization rate, proportion of institutional deliveries, proportion of deliveries attended by skilled personnel, PNC utilization rate and contraceptive rate.3, 5
Child health services comprise of curative and preventive care services. Curative services encompasses treatment of common childhood diseases such as fevers, diarrhea, acute respiratory infections (ARIs) and malnutrition, while preventive services are focused on growth monitoring, promotion of infant feeding, immunization and vitamin
A supplementation. Utilization of child health care can be assessed using the following indicators; coverage rate for each antigen and complete vaccination (based on routine
26 immunization schedule) for children aged 12-23 months, and drop out rate (children who started immunization but failed to complete) and number of children utilizing curative services.3,5
However, some outcome indicators of Maternal and child health include maternal mortality; neo-natal mortality; postnatal mortality; infant mortality; child mortality; prevalence of diarrhoea, bloody diarrhoea, acute respiratory infections (ARI); use of contraception; delivery complication and low birth weight baby.1
2.3 Pattern and level of MCH service utilization
Literature has reported varying levels of accessibility and utilization of maternal and child health services between developed and developing country, even as intra country differences are obvious. In the developed countries majority of the women utilized health facilities for ante natal care services and almost if not all the deliveries are attended to by skilled personnel either a midwife or doctor. In Iraq ANC utilization is 77.6%; traditional birth attendants (TBAs) attend 18% of the total deliveries and 27% are attended by licensed endogenous midwives.3, 16
Studies in India also indicated low utilization of the MCH services provided by the public health care system. A number of deliveries, in fact, are still conducted at home and are attended to by traditional dais under the most unhygienic conditions.1 A review of India National Family Health Survey (NFHS-2) conducted during 1998-99 showed that nearly one-fifth (19.1%) of the mothers did not utilize antenatal care at all.
27 Though, nearly two-third (65.8%) had gone for at least one antenatal checkup, only
44.2% had utilized the minimum expected three checkups. Furthermore, only one third of the mothers (33.1%) had their first ANC checkup during their first trimester of pregnancy, while only one in five mothers (20.1%) had received ‘full ANC’. Only
33.9% of the mothers had delivered in a health facility; 8.9% delivered in home
(whether own or parents) with the help of healthcare professionals; and the remaining
57% of these mothers had delivered in home without the assistance of any healthcare professionals. Irrespective of the place of delivery, nearly one third of the mothers
(31.1%) had gone to the health facility for postnatal checkup within two months of delivery majority of who were mothers who had delivered in a health facility.2
The proportion of first antenatal visits among women in sub Saharan Africa
(SSA) is around 71% and the percent of births attended to by skilled personnel showed a marginal increase from 40% in 1990 to 42% in 2000.5,22 Reports say that level of utilization of maternal services has not shown any significant improvement in Nigeria in recent past. One third of all pregnant women in developing countries do not receive health care during pregnancy and 60% of deliveries take place outside of health facilities, more so only half of all deliveries are assisted by skilled personnel. A study conducted in Oji River Local Government Area (LGA) of Enugu State showed an ANC utilization level of 96%, most of the women studied utilized health centers and general hospitals, however fewer visited private health facilities (9.3%).5 In Nigeria an average of 59% pregnant women attended ante natal care services and only 30% returned to
28 deliver in a health facility. A baseline survey conducted in United Nations Fund for
Population Activities (UNFPA)-assisted states in Nigeria in 2004 revealed that ANC utilization based on the number of women who received ANC during their last pregnancy ranged between 16.5% and 96.8% for Sokoto and Abia States respectively. It was further observed that ANC utilization was higher for southern part than for the northern part of country. The study further revealed that the proportion of women in
Anambra State who received ante natal care during their last pregnancy was 89.0%.4
In Nigeria, rate of delivery in health facilities in 2004 as reported by UNFPA was in the range of 5.7% and 87.9% for Sokoto and Anambra states respectively.4
Uzochukwu et al reported 58.8% of the women studied delivered in the health center, while 17%, 11.4%,5.2% and 7.6% used the secondary health facility, private hospital,
TBA and home delivery respectively.5 A thematic evaluation of the UNFPA supported fifth country programme revealed selective utilization of maternal services as most mothers who patronized the facilities during ANC do not come back to deliver.23
A study in Turkey revealed full vaccination coverage rate as 62.3%, however specific vaccination coverage rates ranged between 72.5% for DPT third dose to 92.3% for both BCG and DPT first dose for the whole country, however Istanbul had 79% coverage of full vaccination in the first year of life, which is also similar to the rate recorded in Italy.24 For Iraq full vaccination coverage rate is lightly lower 60.7%.3
National health facility surveys carried out in India in 1992 and 1998 showed full
29 vaccination of children aged between 12-23 months increased from 58.3% and 39.7% to
73.3% and 53.6% for urban and rural communities respectively.2
The National Immunization Coverage Survey (NICS) states that nationally 7% of rural children and 25% of urban children have been fully immunized. Children in rural areas, especially in the North, are particularly disadvantaged. Between the National
Demographic and Health Survey (NDHS) for 1999 and 2003 the percentage of children aged 12-23 months who received at least one dose of the traditional vaccines (BCG, three doses of DPT and OPV, Measles) by their first birthday rose from 60.9% to
69.4%, indicating that access and uptake had improved. Yet the percentage fully immunized with all doses before 12 months of age fell from 14.3% in 1999 to 11.3% in
2003, and drop-out between first and third dose of DPT increase from 45.7% to 48.1%, indicating growing problems with the continuity of routine immunization (RI) services.25 Full vaccination coverage according to National Demographic and Health
Survey (NDHS) 2003 ranged between 3.7% for North West region to 45% for South
East region.26 A project to assess immunization coverage in 3 states of the federation -
Abia (2 LGAs), Kano (9 LGAs) and Lagos (9 LGAs) showed the following ;In the 9
Kano LGAs, OPV0 rose from 25% to 39%, and OPV1 rose from 30% to 35%, but
OPV3 coverage fell from 32% to 15% during this period. The WHO standard is that a dropout rate greater than 10% is unacceptable. In none of the three states for which data are presented were drop-out rates within that allowable maximum. Indeed, an inspection of drop-out rates from DPTI to DPT3 indicates that completion of coverage
30 is weak in all three states. Completion rates appear stronger in Lagos where the DPTI –
DPT3 drop-out rate is 20%. The rate of completion is the weakest in Kano, indicating a failure in the routine system to identify, follow-up, and monitor drop-out.27 Also, another study in Oji river (a rural setting) on utilization of immunization services revealed an initial increase from 12 per 10,000 in 1993 for measles immunization to 55 per 10,000 in 1997 and subsequent decline to 45 per 10,000 in 2001. Also, coverage for
OPV1 increased from 24 per 10,000 in 1993 to 69 per 10,000 in 1999 and then declined to 60 per 10,000 in 2001.28 From the foregoing, it appears that vaccination rates generally is on the decline in the country.
2.4 Factors influencing utilization of MCH services
A number of factors has been identified as determinants of maternal and child health service utilization, some of the factors include individual socioeconomic status, educational status, access to health facility-distance to facility, cost of services, availability of drugs, availability of skilled staff, attitude of staff, quality of care, availability of staff, waiting time, health policies and health interventions.
Evidence in the past has shown that socioeconomic status influences the utilization of health care including maternal and child health services. Household socioeconomic conditions largely determine their health seeking behaviour. The richer to poorer ratio for utilization of maternal health services as reported by the World bank is 2.8 for the proportion of pregnant women with more than two antenatal care visits
31 and 7.0 for deliveries attended by trained healthcare personnel.29 UNFPA reported that reasons why poor urban women do not seek maternal care include poverty and the more pressing demands of other household expenses, other demands on their time given their many other responsibilities and the absence of supporting infrastructure such as transport and childcare.6 Yesudian reported that the relationship between empowerment factors - education, access to media and standard of living as factors positively influencing the utilization of maternal health care services in rural India. According to the report more than one in every two mothers (54.9%) who were with high school and above level of education received full ANC, whereas among illiterates, less than one in every ten mothers (8.3%) had taken full ANC. Little more than three-fourth of the mothers (76.1%) with higher education had delivered in a health facility, whereas only one sixth of the illiterate mothers (17.6%) had delivered in a health facility.2 A
Ghanaian study reported educational status and income status as primary factors influencing utilization of health services. Studies have shown that the educational level of a mother is one of the significant predictor for utilization of maternal care services.7,9Also in South Africa it is posited that the utilization of maternal healthcare services is affected by such factors as: socio-economic status and other barriers to maternal health facilities.10 Among the factors identified by UNFPA as being responsible for low MCH utilization is poverty and low socioeconomic status of women.23 Uzochukwu et al also reported that maternal health service utilization is worse among poorer families than the relatively rich even in rural Nigeria.29
32 Higher socioeconomic status has been associated with higher utilization of immunization services in United States of America, Italy, Turkey, Puerto Rico, Guinea and Kenya. In Turkey sociodemographic and socio-economic status, size of the population, ability to reach primary healthcare services, and promotion and delivery of private vaccines affects vaccination coverage. Low levels of vaccination coverage were found to be more prominent for poor children. A study of mass measles vaccination in urban Burkina Faso reported that better socioeconomic status was associated with a higher chance of having been vaccinated routinely, but it was not associated with the coverage by National Immunization Days (NIDs).24 Another study in Turkey found that socio-economic factors affected vaccination coverage for deprived groups for both compulsory vaccine coverage especially after the first year of life. However, children from a family with a higher socio-economic status had a higher chance of being fully vaccinated under the age of 5 years. It has been shown in Puerto Rico and Guinea that once a child has entered the national immunization system, completion of vaccination was determined by the mothers educational level, employment status and experience with vaccination services.24 A child of parents in the lowest socio-economic quintile is nearly 12 times less likely to be immunized than children of parents in the highest.
There is a positive correlation between mothers’ education and the fully immunized child: nationally 31.1% of children of mothers with secondary education are fully immunized; the figure for children of mother with no education is 3.9%.30 In general, women who have been through the formal education system and with higher
33 socioeconomic status had greater awareness of immunization activities and benefits, and socioeconomic status was an important predictor of use of immunization services.7
Among other factors known to influence maternal health service utilization are perceived quality of maternal services and satisfaction with maternal services.10 The importance of peoples' perception of quality was demonstrated by Akin and
Hutchinson.10 Uzochukwu also found that the ill and poor people by-passed free or subsidized services in facilities they perceived to be offering low quality services .
Perceived quality is one of the most important determinants of patient's choice of provider and willingness to pay for services.28 In India and South Africa the interaction between the client and the provider of formal health care system is a recognized factor influencing maternal health care.2,10 Some studies found that consumers' satisfaction with health care services in Africa was one of the most important factors determining the utilization of services.10 Determinants of perceptions of quality of services found in
Tanzania include; perceived time spent at the facility, availability of immunizations, availability of MCH services and the staff strength of the health facilities.10 In South
Africa the relationship between women’s perception of quality of care and maternal services utilization has been reported. However, previous efforts to improve maternal health services have failed to appreciate relationship between health care providers and the patients. It was also noted that the quality of care given by health providers is a serious problem in South Africa’s maternal healthcare delivery service.10 In Ghana it
34 was reported that health providers influence male and female utilization through quality of service, practice patterns and affective behaviour.9
A study of health facilities in Oji River, Enugu State revealed a strong association between level of satisfaction and perceived quality of care and utilization of
MCH services. Perceived quality of care was based on availability of prescribed drugs, physical condition of the facilities and providers’ behaviors. The study confirmed the age-long problem of Nigeria public health facilities which were long waiting-times, shortage of health workers and unfriendly dispositions of some health workers. Absence of doctors for all services, staff attitude, non availability of drugs and long waiting time were the primary reasons for non utilization of health centre services which is a reflection of their perception of quality of care for the non-users of health services.
However, no significant association was observed between the absence of doctors and use of delivery services, it might be that the people can use delivery services even if there were no doctors as this is still the domain of midwives.5
Interventions to improve PHC services such as building capacity of health worker to provide care and regular supply of drugs were found to impact positively on the quality of care provided to clients. In 1995 World Health Organization (WHO) pointed out the need to pay attention to improvement in quality of care by enhancing the technical competence of health providers and improvement in interpersonal skills, in addition to availability of basic supplies and equipment, sufficient physical facilities and infrastructure, linkages to other health services and the existence of a functional
35 referral system, all of which are important components of quality maternal services.5,10
Uzochukwu et al observed that a 4-day training of health workers on Integrated
Management of Childhood Illnesses (IMCI) case management resulted in increased utilization on child health services. At the end of the training health workers were better able to assess and classify the child correctly, and to institute proper treatment and communication for malaria, measles, diarrhea and pneumonia. They were also able to immunize more children who were identified in the post intervention period as not having completed their immunization schedule.31 A review of impact of BI on healthcare utilization in Nigeria showed wide variations in utilization and coverage levels amongst facilities in different local government areas. There was increase in service utilization among facilities supported by donor agency in contrast to those supported by government.5
Utilization of maternal health care depends not only on the availability of services but also on different other factors such as distance of health care facility and the opportunity cost of accessing health care.2 Literature for the status of access and use of health care in developing countries identifies cost and distance as the principal factors influencing utilization. The cost problem deprives the poor of access to health facilities whilst distance impedes utilization by those who don't have access to good transport.9 In India 63.4% of the urban women had health facility within 5sq km radius of their reach.2 Poor access to health care both geographically and economically is a known problem in Sub Saharan Africa particularly in the rural areas. Declining health-
36 care expenditure in recent years with many countries spending decreasing proportion of the national budget on health has resulted in inadequate provision and distribution of health services. Quality health services where available are expensive and out of reach of the poor. Increased physical accessibility to Primary Health Centers has been shown to enhance utilization rates.10,32 In Ghana it was observed that distance and service cost were the most important factors influencing health care use in the metropolis, while distance and income emerged as the most important factors in the rural Ahafo-Ano
South District.9 It went on to state that the illiterate and the poor were not found to be more strongly affected by distance. Uzochukwu et al reported that distance was the primary factor influencing utilization of delivery services as the patients are more likely to patronize facilities closest to them.12 Physical accessibility to health facility alone does not guarantee utilization, as perceived cost of services by clients is another significant factor as was noted in Peru. Rural dwellers are known to patronize patent medicine dealers because of they are relatively accessible both financially and geographically.32 Introduction of user charges for some MCH activities like antenatal and childbirth services amongst others during the BI scheme resulted in reduced utilization of services. User fees for MCH services have been reported to be a major impediment to utilization of MCH services. It tends to exclude the poor from accessing vital antenatal and childbirth services. This would potentially defeat one of the major aims of the MCH, since many poor pregnant women, especially in the rural areas that already have very low utilization rates would keep being denied of essential
37 services.5, 12 It has been suggested that a form of social insurance scheme will go a long way in addressing inequity and encourage access to these services by the poor. In rural community in Enugu State, cost consideration was identified as a major factor influencing use of PHC services. However, it has been found that in certain places that cost consideration do not influence the use of maternal services as much as distance and staff attitude.12
Among the population as a whole, only 70% of Nigerians had access to healthcare of any description (public, private, traditional, primary, secondary, and tertiary) in 2001. This figure however is lower in rural areas. Barriers to equitable routine immunization access and uptake remain insurmountable for all too many
Nigerians. Barriers may be gender linked (e.g. women not wishing to see a male health worker; women not being given permission to visit a health facility with their child); financial (e.g. terrain and amount of time needed to trek to the nearest health facility).
There may be opportunity costs (e.g. time taken out from wage labour).33 In the NICS
2003 the second most frequently cited reason for a child not being immunized was that the service was “too far.” In the NW zone this was the most often given reason.
Unfortunately there was no data to indicate what people consider a reasonable distance to travel, nor is there any indication whether “too far” refers to time or distance.
Conventionally planners consider 5km or 1 hour reasonable, but this rule of thumb must be verified in Nigeria’s settings.
UNFPA identified inability of women to take decisions on issues concerning
38 their own health as one of reasons for low utilization of maternal health services. A study of Indian mothers revealed greater health care autonomy is positively associated with maternal health care utilization. Mothers with full healthcare and mobility autonomy were more likely to utilize full antenatal care, deliver in a health facility or at home with professional assistance and visit for postnatal checkup within two months of delivery. Yesudian2 noted that lack of decision making power by a woman could result into lesser timely health seeking behaviour and leads to greater adverse health consequences. Non-egalitarian gender relations deny woman an egalitarian decision making role during health care need, and other family matters. It went on to highlight the strong relationship between the “condition” and “position” of woman. Although the
Indian Government had taken various steps to improve the “condition” of the pregnant women by establishing a large network of health infrastructure and giving priority to maternal care; this was an intervention to improve the “condition” of pregnant woman.
However her “position” remains low due to her lack of power to make choices and take decisions independently in matters related to her own maternal health care. Therefore, the utilization pattern for mothers’ maternal health care was inadequate, incomplete and not timely.2, 34 In Northern Nigeria men control resources, decides when and where the women should have health care. Low female educational and economic empowerment further places her in a disadvantaged position and such cannot influence health seeking behaviour decisions.23
39 Health seeking behaviour decisions, as a factor influencing utilization of immunization, considers decision-makers’ and caregivers’ knowledge, attitudes and behaviour. A routine immunization decision-maker makes the final choice to whether a child receives immunization, whether a single intervention or the full course. While the decision-maker is often the father, especially in the North, this is not always so, e.g. in households where parents share responsibility for health seeking behaviour decisions, in female headed households, or where the father is absent. The caregiver will chiefly be the mother; if she is dead another female household member usually takes on responsibility.35
One of the primary reasons for the non utilization of MCH services may be the lack of knowledge on these services offered by the government, which may be attributed to high illiteracy and lower accessibility of institutions providing the services.
Women that are media-exposed were found to access maternal health services compared to their counterparts who were not media exposed.1,2 In South Africa it was reported that lack of knowledge of maternal danger signs in pregnancy were among the factors responsible for low ANC utilization.10 UNFPA also reported a positive correlation between adequate knowledge of ANC consultation and utilization.4
Incorrect knowledge as to the preventive role of routine immunization is widespread in Nigeria. Quantitative research conducted in six states in 2004 reveals that in rural Enugu, diarrhea, fever, convulsion, vomiting and malaria are believed to be
VPDs, while in rural and urban Kano, malaria, teething problems, vomiting, convulsion
40 and pneumonia are listed. Overall, about 66% of the respondents are able to spontaneously and correctly name at least one VPD while less than half (48%) could name at least two. In general, awareness was highest for polio and measles. In contrast, very few respondents demonstrated awareness for diphtheria. Increased knowledge about immunization and belief in the efficacy of vaccines were associated with higher levels of immunization. When people were exposed to child health information through the media, this was associated with improved immunization practices.7,36 Exposure to radio increased consistently with education and SES, such that those least likely to listen to the radio were illiterate and poor. Those who use public health facilities for treatment of common illnesses are also more knowledgeable about immunization.
Considerable differences were seen in awareness of VPDs by state. Specifically, a clear distinction was found between Northern and Southern states. Adamawa mothers demonstrate significantly greater knowledge of both individual antigens and the complete immunization schedule. Similarly, despite observably greater poverty in the
Adamawa communities, mothers there evince more willingness than their counterparts in Katsina state to incur both monetary and opportunity costs to assure their children’s immunization. A greater number of Adamawa mothers retain Child Health Cards, and it was here that the one fully immunized child (card + history) was met. The primary reason for this greater knowledge and commitment appears to be the presence of the
Garkida community-based health programme.7
41 Government policy directly affects provider characteristics, male and female utilization through distribution, employment and wages, universal education and health insurance policies. Insurance scheme has been advocated as a means of addressing the challenge posed by economic inaccessibility particularly in rural areas. In Ghana, insurance was found to improve health care service utilization.9 In Nigeria the introduction of Petroleum Trust Fund (PTF) by the regime of General Sani Abacha in
1996 led to massive supply of drugs to most health facilities. Consequently, health care utilization increased tremendously during this period. The preceding years were characterized by political and industrial turmoil resulting in low patronage of formal health services in the country. However, some years after the scrapping of PTF the sustainability of the drug revolving fund became a problem and drug stock-out became a norm in health institutions once again.5 In contrast, in spite of the Indian government’s effort to reach out to pregnant women in all parts of the country to provide all components of maternal health care free or with nominal charges, utilization of maternal health care remains low in the country.2
In recent times, rumours, incorrect information and fear has resulted in reduction in utilization of immunization. Fears regarding routine immunization are expressed in many parts of Nigeria, particularly in Northern states where there is widespread belief that enemy foreign agents promote immunization with a hidden agenda. It is feared that it is aimed at reducing the local population and increase mortality rates in developing countries. Understanding of the links between preventive healthcare and good health
42 and decision-makers and caregivers are often weak; as a result, fears as to the possibility of infection and disease can grow. Some wonder why a healthy child should receive an injection. There are also widespread misconceptions that immunization can prevent all childhood illnesses and when this fails, parents lose faith in immunization.7
Lack of confidence and trust in routine immunization as effective health interventions appears to be relatively common in many parts of Nigeria.37 A 2003 study in Kano state found that 9.2% of respondents (mothers aged 15-49) evinced ‘no faith in immunization’, while 6.7% expressed “fear of side reactions”. For many, immunization is seen to provide at best only partial immunity, e.g. Kano and Enugu.7 Many negative attitudes towards routine immunization in the North can be traced to what are widely perceived to be intrusive and culturally insensitive polio sub national immunization days (S/NIDs). Another frequently expressed view linked to the number of NIDs is that routine immunization must be unimportant. ‘Polio fatigue’ has led to ‘routine immunization fatigue’, according to personnel on communication from United Nation
(UN) and State Ministry of Health (SMOH) staff in Bauchi and Kano states in January
2005. Therefore, they cannot understand the overwhelming weight placed on this one intervention, to the detriment of all routine immunization.
2.5 Urban -Rural difference
In the year 2000 over 30% of the African population lived in the urban area. The recent UNFPA state of world population 2007 revealed that by the year 2008 first time
43 in history, more than half its human population, 3.3 billion people, will be living in urban areas and by 2030, this is expected to swell to almost 5 billion. It further predicted that the next few decades will see an unprecedented scale of urban growth in the developing world. This will be particularly notable in Africa and Asia where the urban population will double between 2000 and 2030.6 It has also been noted that rural and urban populations differ in several ways including their cultural practices, socioeconomic and demographic characteristics, availability and accessibility to formal and informal treatment sources, provision of basic infrastructure and childhood nutritional status.2,9 Women in rural areas were less likely to have a Western-trained health professional in attendance at delivery. Mothers in rural areas are not provided with antenatal care and delivery by trained persons and may be more likely to develop postnatal complications that endanger their lives.2 Health facilities are concentrated in the main urban centers to the detriment of the rural population. The rural areas are often characterized by poor road access thus aggravating the effect of geographical accessibility.9
The percentage of urban population in Nigeria is about 44.1% with an urban population annual growth rate of 5.5. Nigeria's infant mortality rate is about 96 per a thousand live births in rural areas against 75 per a thousand live births in urban areas and only 89% and 59% of pregnant women in urban and rural areas respectively sought pre-natal care.9 Health care in Nigeria currently concentrates on the urban population despite the rapid urbanization, rural-to-urban migrations. Although, the disease pattern
44 do not differ significantly between urban populations in the country, however access and utilization to health care services is better for urban than rural communities. The urban residents are more likely to use preventive measure as being more exposed to the media and also have better socioeconomic status than their rural counterparts. This is corroborated by a study in Kenya which reported that preventive health seeking behaviour for children is clearly better in urban than rural areas.5
However, the recent increase in urbanization is posing a new health challenge as some urban dwellers of low socioeconomic status do not seem to fair well health wise.
UNFPA reports that women in urban settings are far more likely than their rural counterparts to report having ever experienced skilled attendance and access to emergency care which explain why maternal mortality is generally lower in urban areas, where women are three times more likely to deliver with skilled health personnel than women in rural areas. However, poor urban women are less likely to deliver with a skilled birth attendant. For example, only 10-20% of women deliver with skilled health personnel in the slums of Kenya, Mali, Rwanda and Uganda, compared to between 68 -
86 % in non-slum urban areas.6 These findings agrees with the report of study in
Northern Nigeria which observed that the vast majority of women in rural areas do not have access to antenatal, delivery and postpartum care services.38
In Turkey, full vaccination coverage is lower in rural areas (urban 62.9%, rural
36.5%) than in urban areas. Nearly, half of the immigrants came from rural areas
(44.5%). It is assumed that parents of rural origin were less likely to complete their
45 children’s vaccination schedule because they had used vaccination services inadequately in the past.24 A study of knowledge and utilization of maternal health and child health services in Delhi slums shows that the vaccination rate in these slum areas failed to attain the goal of universal immunization against the major vaccine preventable diseases.39
A review of child health inequities in Sub Saharan Africa showed that rural areas carry higher disease burden than the urban areas but that intra-urban disparity exists between the poor and non poor households.40 In Nigeria the picture is not different as most rural households have limited access to health facility, are of poor socioeconomic status and have lower literacy levels than their urban counterparts. Immunization coverage rate is lower in the rural than the urban areas. Even during the NIDs the rural communities with hard to reach terrain are also less likely to be reached. Irregular supply of vaccine and poor cold chain infrastructure affect the rural communities more than the urban areas.
46 CHAPTER THREE
MATERIALS AND METHOD
3.1 Study Areas
The study areas were Nnewi North Local Government Area and Dunukofia Local
Government Area in Anambra State, South East Nigeria. Although, the former is an urban area and the latter a typical rural community, some similarities exist between the two towns. Their climate is a typical rain forest type with a warm dry season occurring from November to March; a rainy season from April to October and a cold, dry and dusty harmattan from December to January. The two towns are approximately 32km apart.
Numerous patent medicine stores as well as herbal homes are scattered all over the communities. The major means of transportation are motor cycles and motor vehicles. Power supply from the national grid is erratic in both communities. Malaria is the most prevailing disease in these communities. Other common diseases include respiratory tract infections, diarrheal diseases and worm infestations.
3.1.1 Nnewi North LGA
Nnewi North Local Government Area is an urban community that is continuously attracting new immigrants on daily basis. It has a geographical area of approximately
72sqkm. Nnewi town is an urban community made up of four (4) main villages viz:
Otolo, Uruagu, Umudim and Nnewi-Ichi in their order of seniority. It has ten (10)
47 wards. It has an approximate total population of 157,569 (based on the 2006 National
Population Census) 79,962 males and 77,607 females.40 The town is the third largest in the state after Onitsha and Awka (the State Capital). It is located at about 10kms from
Onitsha and about 20kms from the State capital, Awka.
Nnewi is famed for commerce and industry. The industrial dimension of the town attained it’s height during the rehabilitation process, which took place in the town after the Nigerian civil war. Industrial outputs include lubricants, chemicals, machine spare parts, food, stationery, household equipments, etc. In commerce Nnewi ranks first in the importation of fairly used motorcycles in the country and ranks very high in the importation of motor and motor cycle spare parts, electronics from Europe, the United
States and the Far East. There are few manufacturing and motorcycle assembly industries, with heavy presence of many financial institutions, a reflection of the volume of business activities going on in the town. Most inhabitants of the town are traders, while few are civil servants, artisans and farmers.
The source of water supply is mainly through private boreholes, as the municipal water supply has broken down a long time ago. Their major method of sewage disposal is the water closet, but a few use the pit latrine. Open dumping of refuse is a very common practice. The town has social amenities like electric power supply, post offices, banks, markets, police stations and churches.
Numerous health facilities abound in Nnewi. These include the Nnamdi Azikiwe
University Teaching Hospital, ten PHC centers, twelve health posts and a number of
48 private hospitals. A total of thirty-five (35) health facilities offer MCH services in the town (see appendix).
3.1.2 Dunukofia LGA
Dunukofia LGA is a rural community made up of six (6) communities viz:
Ifitedunu, Ukpo, Ukwulu, Umunnachi, Nawgu, Umudioka. It has fourteen (14) wards. It has a geographical area of approximately 79sq km. The total population of males and females according to the 2006 National Population Census is 50,731 males and 45,657 females; giving a total of 96,382.41 It is located about 7kms from the state capital,
Awka.
The LGA consists of inhabitants who are mostly subsistent farmers, petty traders and a few civil servants. The sources of water supply are from rain water, local streams and shallow wells, as well as boreholes. Their major method of sewage disposal is the pit latrine but a few uses the water closet, while a sizeable number defecate in the bush.
Open dumping of refuse is a very common practice. Electric power supply, a post office, bank, a market and churches are the social amenities in this town. There are no industries in this town.
Dunukofia LGA houses the Primary Health Care Unit of the Nnamdi Azikiwe
University Teaching Hospital at Ukpo. The other health facilities are five PHC units run by the LGA, six health posts and seven private hospitals. A total of twelve (12) health facilities offer MCH services in the town.(see appendix).
49
3.2 Study Population
The target populations were mothers with children aged 0–59 months in both communities who consented to being studied. A sample of the population was studied.
3.3 Study Design
This is a comparative cross-sectional descriptive study involving two communities, one urban and one rural. A quantitative assessment of MCH utilization in both communities was done and subsequent comparisons were carried out.
50 3.4 Sample Size Estimation:
Comparison of two groups: urban/rural
n = 2Z2pq 42
d2 where n = Minimum sample size
z = standard normal deviate (usually 1.96) at 95% confidence limit.
p = Proportion of mothers utilizing MCH services in Anambra State, and
is 89.0%.4
q = 1 – p
d = degree of accuracy desired set at 0.05
:. n = 2 (1.96)2 (0.89 x 0.11)
(0.05)2
= 7.68 x 0.0979
0.0025
= 305
With anticipated 90% response rate, the sample size thus selected
305
= 0.9
Therefore, a total of 338 respondents constituted the sample size for each group.
51 3.5 Inclusion Criteria
A mother of a child aged 0 - 59 months was recruited for the study.
3.6 Sampling Technique
Multistage, cluster sampling technique was used in selecting the subjects for the study.
Out of the twenty-one Local Government Areas that make up Anambra state, the
National Population Commission (NPC) designated seven LGAs as urban LGAs, while the remaining fourteen LGAs are rural LGAs (Appendix I). With each stratum of LGAs,
(that is urban and rural LGAs) as the sampling frame, simple random sampling using simple balloting was used to select Nnewi North and Dunukofia LGAs as the study
Local Government Areas in urban and rural areas respectively.
Nnewi North LGA is made up of four (4) towns which are:-
Otolo,Nnewichi,Uruagu and Umudim. While Dunukofia LGA is comprised of six (6) towns namely-Ifitedunu,Ukpo,Nawgu,Ukwulu,Umudioka and Umunnachi. By simple random sampling, two (2) towns-Nnewichi and Umudim, and two (2) towns-Ukpo and
Ifitedunu were selected from Nnewi North and Dunukofia LGAs respectively. The two selected towns in Nnewi North LGA are made up of 2 wards each, while in Dunukofia
LGA, Ifitedunu and Ukpo has 3 wards each. Therefore, a total of four wards and six wards were sampled in Nnewi North and Dunukofia LGAs respectively. Each ward is representative of a cluster and all the eligible households in the selected communities
52 were recruited for the study. From each ward in Nnewi North LGA a total of eighty-six
(86) respondents were interviewed, while a total of fifty-six (56) respondents were also interviewed in the selected wards in Dunukofia LGA. An eligible household is a household with a woman with a child aged 0-59 months. Where a selected household was not eligible, it was replaced with an eligible household selected by simple random sampling. The process was continued until the required sample size for each ward was obtained.
3.7 Data Collection
A semi-structured, pre-tested, interviewer administered questionnaire was used to collect information from the respondents. For effective data collection research assistants were trained on the interview technique, vernacular translation and accurate record keeping to enhance validity. The questionnaire was translated into the local language and back to English and both versions taken to the field by the interviewers who have good knowledge of both languages. The study participants were visited and interviewed at their homes under close supervision of the investigator.
Information was collected from the respondents on their age, marital status, socioeconomic status which was assessed using occupation, educational status and ownership of household items. Also, information on the occupation and educational status of their spouse was collected; as well as the age, sex and number of children they have. Mother’s knowledge of MCH services, their perception and utilization of MCH
53 services were assessed. Also, their choice of place for ANC, delivery, PNC and immunization and also factors influencing their use of such services were assessed.
Vaccination cards were checked if they were available. Where the vaccination status could not be verified, the child was considered not to be fully vaccinated. Full vaccination was assessed based on recommended vaccines of the National Programme on Immunization (NPI) routine immunization schedule. (See Appendix)
A 2 year retrospective review of records of public health facility records in the selected wards was done to validate the findings of the household survey. Records reviewed include ANC attendance, delivery and PNC for maternal services and immunization and Vitamin A records.
54 3.8 Data Analysis
Data collected were entered into the computer and analyzed using SPSS version
13. Relevant means and standard deviations were calculated. Chi square was done to ascertain the differences between urban and rural in relationships between demographic and socioeconomic characteristics, knowledge and perception of MCH services, geographic accessibility and MCH utilization. P-value was set at 0.05. Major findings were represented with appropriate tables and graphs for easy appreciation.
Delivery rate was assessed based on the proportion of clients who attended ANC at least once that delivered in the facility. The difference between total ANC attendance and delivery and also the percent difference in delivery was used to discover the gap between ANC attendance and delivery.
PNC utilization rate was assessed based on the proportion of women who attended ANC at least once that visited facility 6 weeks after delivery for checkup.
Immunization coverage records were used to assess immunization completion rates and drop out rates. For immunization dropout rate, this was calculated using DPT antigen with the formula DPT1 – DPT3
DPT1
Immunization coverage was calculated as total number of children less than 5 years immunized with DPT3 and measles vaccines divided by the target population for that year.
55 3.9 Pretest
The questionnaire was pre-tested among twenty (20) mothers with children aged
0-59 months of age residing at Awka and Neni; who were not part of the study population but share similar characteristics with the study areas. Findings of the pretest was used to determine the following;
. Reactions of respondents to the research procedures and the questions.
. Appropriateness of study design and research tool.
. Appropriateness of format and wording of the questionnaires.
. Time needed to carry out interviews.
. Feasibility of the designed sampling procedures.
. Feasibility of the designed procedure for data collection and analysis
56 3.10 Study Schedule This study lasted for a period of five (5) months, split as follows: Activities Duration (represented in weeks)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1. Proposal assessment
2.Recruitment of research assistants
3. Training of research assistants
4. Pretest of questionnaire
5. Data collection
* Questionnaire administration
*Field supervision and cleaning of questionnaire
*Review of hospital records
6.Collation and recording of data
7. Data analysis 57 8. Report writing 3.11 Ethical Consideration
Ethical clearance was obtained from the Ethical and Disciplinary committee of
Nnamdi Azikiwe University Teaching Hospital, Nnewi. The letter of approval is hereby attached (see appendix). Permission was sought and obtained from the Igwes
(traditional rulers) of the two communities. Permission was also obtained from the heads of the public health facilities offering MCH services for the use of data from their facility records for the study. Informed consent was obtained verbally from each mother participating in the study after proper and thorough explanation of details of the study.
3.12 Limitations
1. As is common with household surveys, repeated visits were made to some of the
households before seeing the mother residing in it for interview. After three
consecutive visits mothers not seen were excluded from the study.
2. There was unwillingness to be interviewed on the part of some of the
respondents. However, the rapport and confidence that was established with the
help of health workers encouraged participation in the study.
3. The immunization cards of older children were not readily available considering
our record keeping attitude. For those without immunization cards, their
immunization status was considered to be incomplete and non-valid for the study;
but the public health facility reviews helped to validate findings.
58 3.13 Definition of key variables
Maternal and Child Health-Field of work related to the physical, mental and
emotional health of women before, during and after childbirth; and of infants and
children.
Maternity Home-Means any premises used or intended to be used for the
reception of pregnant women or of women immediately after childbirth.
Immunization coverage-Percentage of children aged 19 to 35 months who have
received four or more doses of DPT, three or more doses of poliovirus vaccine,
one or more doses of any measles containing vaccine, three or more doses of Hib,
and three or more doses of HepB vaccine.
Dropout Rate-Percentage point difference between successive doses of a vaccine,
expressed as a percentage of the first dose.
59 CHAPTER FOUR
RESULTS
In Nnewi North LGA 367 mothers were approached and after careful explanation of the concept of the study, 350 of them participated. However, in Dunukofia LGA 346 mothers participated from the 355 mothers who were approached for the study. A total of twelve questionnaires were discarded due to errors in the urban community, while in the rural community eight questionnaires were discarded due to errors. Thus a total of
338 respondents were respectively studied in the two communities.
Table 1: Sociodemographic characteristics of respondents
Demographic Variable Urban Rural χ2 p-value Frequency Frequency (%) (%) [n = 338] [n = 338] Age group (Years): < 20 6 (1.8) 24 (7.1) 11.302 0.001* 20 – 24 17 (5.0) 36 (10.7) 1.272 0.259 25 – 29 74 (21.9) 73 (21.6) 0.009 0.926 30 – 34 109 (32.3) 79 (23.4) 6.631 0.010* 35 – 39 68 (20.1) 61 (18.0) 0.469 0.493 ≥ 40 41 (12.1) 58 (17.1) 3.420 0.064 No response 23 (6.8) 7 (2.1) 8.930 0.003* Marital status: Married 286 (84.5) 279 (82.4) 0.528 0.467 Single 30 (8.9) 32 (9.5) 0.071 0.790 Widowed 8 (2.4) 11 (3.3) 0.487 0.485 Separated 2 (0.6) 6 (1.8) F2.024 0.155 Divorced 2 (0.6) 3 (0.9) F0.201 0.654 No response 10 (3.0) 7 (2.1) 0.543 0.461
60
Educational status: No formal education 0 (0.0) 16 (4.7) F16.300 0.000* Primary 13 (3.8) 76 (22.5) Secondary 87 (25.7) 184 (54.4) 293.149 0.000* Tertiary 229(67.8) 55 (16.3) No response 9 (2.7) 7 (2.1) 0.256 0.613 Number of pregnancies: Primigravida (1st pregnancy) 38 (11.2) 43 (12.7) 0.351 0.554 Multigravida (2nd – 4th 228(67.5) 167 (49.4) 22.662 0.000* pregnancy) Grand multigravida (≥ 5 67 (19.8) 125 (37.0) 24.471 0.000* pregnancies) No response 5 (1.5) 3 (0.9) 0.506 0.477 Parity: Primipara (1 child) 47 (13.9) 51 (15.1) 0.191 0.662 Multipara (2 – 4 children) 228(67.4) 172 (50.9) 19.202 0.000* Grand multipara (≥ 5 children) 54 (16.0) 111 (32.8) 26.049 0.000* No response 9 (2.7) 4(1.2) 1.961 0.161 Religion: Roman Catholic 149(44.0) 167 (49.4) Anglican 121(35.8) 98 (29.0) Pentecostal 62 (18.3) 69 (20.4) Islam 1 (0.3) 0 (0.0) 6.468 3.197 Traditional Religion 0 (0.0) 1 (0.3) No response 5 (1.5) 3 (0.9) *Statistically significant F = Fischer exact
61 Table 1 summarizes the sociodemographic characteristics of the respondents from both urban and rural areas. The majority of the respondents were aged 25-34 years in the urban (54%) and rural (45.4%) areas. Most respondents in both localities were married. All the respondents in the urban area had formal education; and most of them
(67.8%) had tertiary education, while 16.4% of those in the rural communities had no formal education and majority of them (54.4%) had secondary education.
Respondents that had 2nd to 4th pregnancies (multigravida) were 228 (67.5%) and 167 (49.4%) in urban and the rural areas respectively. Women that have had ≥ 5 pregnancies (grand multigravida) were more in the rural area 125 (37.0%) as against 67
(19.8%) in the urban area.
The greatest number of the respondents had between 2 to 4 children (multipara),
228 (67.4%) in the urban area and 172 (50.9%) in the rural area. Also in the rural area
111 (32.8%) have 5 children (grand multipara) while in the urban area 54 (16.0%).
62 Table 2: Comparison of mean values of urban and rural dwellers
Variable Urban Rural t-test p-value
Mean±SD Mean±SD
Age (years) 32.3±5.9 (n = 315) 31.6±7.7 (n = 331) 1.29 0.197
Number of pregnancies 3.3±1.5 (n = 333) 3.9±1.9 (n = 335) 4.53 0.000*
Number of surviving 3.0±1.4 (n = 329) 3.6±1.8 (n = 334) 4.79 0.000* children
*Statistically significant
Table 2 summarizes the comparison of mean values of urban and rural dwellers.
The mean age of the urban women was 32.3 ± 5.9 years, while their rural counterpart
was 31.6 ±7.7 years.
Women in rural had greater number of pregnancies and surviving children than
the urban women. The average of number of pregnancies and surviving children were
3.3±1.5 and 3.0±1.4 and 3.9±1.9 and 3.6±1.8 for Nnewi North LGA and Dunukofia
LGA respectively. Women in the rural areas had more pregnancies (t=4.53, p<0.05) and
have more surviving children (t=4.79, p<0.05) than mothers in the urban areas.
63 Table 3: Household decision maker on health issues
Decision maker Urban Rural χ2 p-value Frequency (%) Frequency (%) Couple 243 (69.1) 165 (48.8) 37.613 0.000* Spouse 54 (16.0) 98 (29.0) 13.232 0.000* Self 41 (12.1) 54 (16.0) 2.070 0.150 Mother-in-law 3 (0.9) 14 (4.1) F 6.034 0.009* Others 3 (0.9) 2 (0.6) F 0.000 1.000 No response 3 (0.9) 5 (1.5) 0.126 0.722 Total 338 (100.0) 338 (100.0) *Statistically significant F = Fischer exact
Table 3 shows significant difference in the pattern of household decision making process in both localities. Most (69.1%) household decisions on health issues in the urban communities were more likely to be made by both partners, compared to 48% in the rural communities, while either spouse in the rural area decided on health issues alone.
64 Table 4: Distance of nearest health facility from place of residence
Distance (km) Urban Rural Frequency (%) Frequency (%) 0 – 5 224 (66.3) 212 (62.7) > 5 77 (22.8) 100 (29.6) No response 37 (10.9) 26 (7.7) Total 338 (100.0) 338 (100.0) χ2 = 5.240, df = 2, p = 0.073
Table 4 shows the distance of nearest health facility from place of residence.
Majority of the women reside within 5 km radius from the nearest health facility, however 23% and 30% of the women reside beyond 5 km in the urban and rural areas respectively. There was no significant difference in the relative distance of facility from place of residence in both localities.
65 Table 5: Socioeconomic status and ownership of personal household items
Item Urban Rural χ2 p-value Frequency (%) Frequency (%) [n = 338] [n = 338] Personal means of mobility: Car 172 (50.9) 74 (21.9) 61.376 0.000* Motorcycle 68 (20.1) 79 (23.4) 1.052 0.305 Bicycle 5 (1.5) 31 (9.2) 19.834 0.000* None 93 (27.5) 154 (45.5) 23.738 0.000* Radio 200 (59.2) 216 (63.9) 1.600 0.206 Television without 178 (52.7) 136 (40.2) 10.491 0.001* cable/satellite Telephone 158 (46.7) 117 (34.6) 10.305 0.001* Television with 137 (40.5) 35 (10.4) 81.131 0.000* cable/satellite *Statistically significant
On personal means of mobility, more urban households owned cars (χ2=61.35,
p=0.000), while their rural counterparts owned more bicycles (χ2=19.83, p=0.000).
More rural households owned radio sets, but a significant proportion of the urban
households owned televisions with or without cable/satellite and telephone.
66 Table 6: Knowledge of mothers on utilization of MCH services
Knowledge Urban Rural χ2 p-value Frequency (%) Frequency (%) [n = 338] [n = 338] A pregnant woman should 324 (95.9) 302 (89.3) 10.453 0.001* visit a health facility 6 weeks after delivery for check up A pregnant woman should 321 (95.0) 282 (83.4) 23.358 0.000* make at least 3 ANC visits before delivery Every child should be 320 (94.7) 310 (91.7) 2.333 0.127 immunized against all the VPDs A pregnant woman should be 319 (94.4) 302 (89.3) 5.720 0.017* delivered by a skilled attendant (doctor or midwife) A pregnant woman should 314 (92.9) 281 (83.1) 15.275 0.000* start ANC within the first 3 months of pregnancy *Statistically significant
Knowledge of utilization of MCH services in both localities was high, however women in the urban areas had better knowledge of MCH services provided in the health facilities than the rural women as shown by table 6. Of all indices used for assessing knowledge of MCH utilization, they demonstrated better knowledge than their rural counterparts except for immunization of children against all vaccine preventable diseases.
67 Table 7: Perception of mothers on utilization of MCH services
Perception Urban Rural χ2 p-value Frequency (%) Frequency (%) [n = 338] [n = 338] Immunization protects 325 (96.2) 322 (95.3) 0.324 0.569 children from major killer diseases ANC attendance is important 320 (94.7) 302 (89.3) 6.521 0.011* to detect problems in pregnancy and to correct them Visit to health facility after 6 318 (94.1) 291 (86.1) 12.078 0.001* weeks of delivery can help mothers plan their family Pregnant women should 314 (92.9) 287 (84.9) 10.933 0.001* deliver at only health facilities where there is a doctor/midwife The timing of starting ANC is 61 (18.0) 128 (37.9) 32.969 0.000* not important *Statistically significant
Most of the mothers studied had good perception of maternal and child health service utilization, although those from the urban area demonstrated better perception of maternal and child health care service utilization than the rural women, however there was no significant difference in the perception of child health care service utilization in both localities.
68 Table 8a: Utilization of MCH services regarding ANC
Utilization Urban Rural χ2 p-value Frequency (%) Frequency (%) [n = 338] [n = 338] Attendance of ANC during last pregnancy 324 (95.9) 316 (93.5) 1.878 0.171
Place of attendance of ANC: Private hospital 157 (46.4) 67 (19.8) 54.081 0.000* Public health facility 109 (32.2) 96 (28.4) 1.183 0.277 Maternity homes 59 (17.5) 149 (44.1) 56.250 0.000* TBA 1 (0.3) 3 (0.9) F 0.251 0.616 Others 4 (1.2) 1 (0.3) F 0.806 0.369 Did not attend 8 (2.4) 22 (6.5) 6.837 0.009* Time of first attendance (weeks): 1 – 12 (first trimester) 326 (96.4) 307 (90.8) 8.966 0.003* > 12 12 (3.6) 31 (9.2) *Statistically significant F = Fischer exact
Most women in both localities attended ante natal care consultation in a health
care facility in both Nnewi North and Dunukofia during their last pregnancy. Most of
them also commenced ANC within the first trimester. Significant proportion of the
women from Nnewi North (46.4%) utilized the private hospitals for ANC services (χ2
=54.08, p<0.05), while those from Dunukofia were more likely to visit maternity homes
(χ2=56.25, p<0.05). Also, women in the urban areas were more likely to make their first
ANC visits within the first trimester (χ2=8.99, p=0.003).
69 Table 8b: Mean number of ANC visits before delivery
Utilization Urban Rural t-test p-value Mean±SD Mean±SD [n = 312] [n = 296] ANC visits before delivery 8.0±4.2 5.9±2.4 7.52 0.000*
*Statistically significant
Table 8b shows the mean ANC visits before delivery. It shows that the mean number of visits in urban and rural areas were 8.0±4.2 and 5.9±2.4 respectively and the difference was significant statistically (t = 7.52, p <0.05).
70 Table 9: Reason for non-attendance of ANC during last pregnancy
Reason Urban Rural Frequency (%) Frequency (%) [n = 14] [n = 22] Health facility is far 6 (42.8) 4(18.2)
Cannot afford cost of 3 (21.4) 15(68.2) delivery Long waiting time 2 (14.3) 1(4.5)
Poor attitude of staff 0 (0.0) 2(9.1)
No reason 3 (21.5) 0 (0.0)
Table 9 shows the reasons for non-attendance of ANC during last pregnancy by the respondents. Distance was the commonest reason given by the non-attendees in the urban area (42.8%), however inability to afford the cost of delivery was the commonest reason for non-utilization of ante natal services among the rural respondents (68.2%) against 21.4% in the urban respondents. Other reasons mentioned by the respondents in the rural area include poor attitude of staff and long waiting time.
71 Table 10: Utilization of maternity services among the respondents
Utilization Urban Rural Χ2 p-value Frequency (%) Frequency (%) [n = 338] [n = 338] Place of last delivery: Private hospital 171 (50.5) 64 (18.9) 94.681 0.000* Public health facility 98 (29.0) 75 (22.2) 4.109 0.043* Maternity homes 57 (16.9) 148 (43.8) 57.977 0.000* TBA 1 (0.3) 11 (3.3) F6.872 0.009* Others- home 3 (0.9) 17 (5.0) F0.708 0.003* No response 8 (2.4) 23 (6.8) 7.607 0.006* Delivery was attended to by 301 (89.1) 265 (78.4) 14.072 0.000* doctor/midwife Person who decided choice of place of delivery: Couple 213 (63.0) 173 (51.2) 9.662 0.002* Self 85 (25.1) 63 (18.6) 4.187 0.041* Spouse 16 (4.7) 49 (14.5) 18.536 0.000* Mother 6 (1.8) 22 (6.5) 9.538 0.002* Mother-in-law 1 (0.3) 11 (3.3) F6.872 0.009* Others 1 (0.3) 4 (1.2) F0.806 0.369 No response 16 (4.7) 16 (4.7) 0.000 1.000 *Statistically significant F = Fischer exact
Choice of place of maternity services followed similar pattern as the ANC consultation. Half of the women in the urban area delivered in private hospitals (50.5%) while the remainder delivered in public health facility (29.0%), maternity homes
(16.9%) and at home (0.9%), while, most (43.8%) of the women in the rural area delivered in maternity homes, followed by health centers (22.2%) and private hospitals
(18.9%). More so, more rural women delivered at home and by TBA. Skilled birth attendance was more in the urban area (89.1%) than in the rural area (78.4%). Majority of women in the urban area (either singly (25.1%) or with their spouse (63.0%))
72 decided on the place of delivery, compared to 70% of them in the rural area. Twenty five per cent of the women in the rural area were not involved in the decision on the choice of place of delivery compared to 7% of them in the urban area.
73 Table 11: Mothers reasons for not delivering in a health facility
Reason Urban Rural χ2 p-value Frequency (%) Frequency (%) N=37 N=73 Husband’s decision 11 (29.7) 15 (20.5) 0.640 0.424 Could not afford it 5 (13.5) 39 (53.4) 28.102 0.000* Health facility too far 2 (5.4) 12 (16.3) F1.549 0.213 My decision 3 (8.1) 1 (1.4) 1.789 0.181 No ready means of transport 1 (2.7) 4 (5.5) F0.031 0.860 Others 2 (5.4) 2 (2.7) F0.028 0.868 No response 13 (35.1) 0 (0.0) F25.812 0.000 *Statistically significant F = Fischer exact
Commonest reasons for non-facility delivery in the urban areas was husband’s decision (29.7%) and cost (13.5%), while cost (53.4%), husband’s decision (20.5%) and distance (16.3%) were major reasons for non facility delivery in the rural areas as shown by table 11.
74 Table 12: Utilization of MCH services regarding postnatal care
Utilization Urban Rural χ2 p- Frequency Frequency (%) value (%) [n = 338] [n = 338] Went back to health worker 6 weeks 287 (84.9) 279 (82.5) 0.695 0.405 after delivery Did not go back to health worker 6 51 (15.1) 59 (17.5) weeks after delivery Reason for 6 weeks postnatal visit: [n = 287] [n = 279] To make sure I was back to normal 192 (66.9) 128 (45.9) 25.440 0.000* Baby needed immunization 169 (58.9) 159 (57.0) 0.209 0.648 Midwife said so 19 (6.6) 34 (12.2) 5.164 0.023* I wanted to start family 13 (4.5) 30 (10.8) 7.804 0.005* planning My ill health 11 (3.8) 8 (2.9) 0.406 0.524 Reason for no postnatal visit: [n = 51] [n = 59] Could not afford it 8 (15.7) 30 (50.8) 14.956 0.000* My decision 6 (11.8) 6 (10.2) 0.072 0.789 Health facility too far 0 (0.0) 11 (18.6) F9.241 0.002* Not planned 7 (13.7) 1 (1.7) F3.162 0.075 Dislike of facility 4 (7.8) 0 (0.0) F2.263 0.132 Husband’s decision 1 (2.0) 2 (3.4) F0.000 1.000 No ready means of transport 0 (0.0) 3 (5.1) F1.339 0.247 No response 25 (49.0) 6 (10.2) 20.399 0.000* *Statistically significant F = Fischer exact
Table 12 shows pattern of postnatal care utilization in both localities. Majority of the women in both localities had postnatal consultation within 6 weeks after delivery.
There was no significant difference in the pattern of post natal care utilization in both localities (χ2=0.695, p=0.405). Commonest reasons mentioned by the mothers for PNC utilization were to make sure she was back to normal and baby’s need for immunization. However, more rural women visited the health facility after six weeks
75 for reasons of family planning and because of need to obey the midwife. Distance
(18.6%) and cost (50.8%) were also the commonest reasons for non utilization of post natal care in the rural area; cost (15.7%) and “did not plan for it” (13.7%) were the reasons why women in the urban area did not.
76 Table 13: Utilization of MCH services regarding immunization
Utilization Urban Rural χ2 p-value Frequency (%) Frequency (%) [n = 338] [n = 338] Last child was ever 252 (74.6) 246 (72.8) 0.275 0.600 immunized
Last child not immunized 86 (25.4) 92 (27.2)
Presence of immunization card 178 (52.7) 185 (54.7) 0.292 0.589
Absence of immunization card 160 (47.3) 153 (45.3)
Majority of the women in both urban and rural LGAs had ever immunized their last child (χ2=0.275, p=0.600), while about a quarter did not, but about half of the women had immunization cards for their last child.
77 Table 14: Children’s completion of immunization
Vaccine Mothers’ Response Validated by χ2 p-value Immunization Card Frequency (%) Frequency (%) Urban [n = 252] [n = 178] BCG 252 (100.0) 178 (100.0) 0.001 1.000 OPV 217 (86.1) 177 (99.4) 24.152 0.000* DPT 223 (88.5) 178 (100.0) 21.966 0.000* HBV 218 (86.5) 176 (98.9) 20.803 0.000* Measles 244 (96.8) 178 (100.0) 5.758 0.016* Yellow fever 233 (92.5) 174 (97.8) 5.771 0.016* Vitamin A 235 (93.3) 174 (97.8) 4.545 0.033* Rural [n = 246] [n = 185] BCG 242 (98.4) 180 (97.3) 0.599 0.439 OPV 200 (81.3) 168 (90.8) 7.652 0.006* DPT 193 (78.5) 165 (89.2) 8.648 0.003* HBV 162 (65.9) 158 (85.4) 21.110 0.000* Measles 210 (85.4) 170 (91.9) 4.311 0.038* Yellow fever 202 (82.1) 161 (87.0) 1.918 0.166 Vitamin A 182 (74.0) 139 (75.1) 0.074 0.076 *Statistically significant
Table 14 shows that based on mother’s response and by validation with the child health card for immunization, most children in the urban areas were more likely vaccinated against any of the vaccine preventable diseases or receive vitamin A supplementation than those from rural areas, except for BCG.
78 Table 15: Mothers/caregivers reasons for non completion of child’s immunization
Reason Urban Rural χ2 p-value Frequency (%) Frequency (%) [n = 46] [n = 126] Vaccine not available 18 (39.2) 36 (28.5) 1.744 0.187
Place of immunization too far 8 (17.4) 17 (13.5) 0.412 0.521 Time of immunization not 7 (15.2) 14 (11.1) 0.530 0.467 convenient
Unaware of the need for 4 (8.7) 8 (6.3) F 0.190 0.592 immunization
Postponed until next time 3 (6.5) 15 (11.9) 0.547 0.460 Lack of money 2 (4.3) 12 (9.5) 0.614 0.433 Vaccinator absent 2 (4.3) 7 (5.6) F 0.000 1.000 Fear of side reactions 1 (2.2) 1 (0.8) F 0.000 1.000 Long waiting time by 1 (2.2) 3 (2.4) F 0.000 1.000 mothers
Lack of confidence/ trust 0 (0.0) 6 (4.8) F 1.076 0.300
Others 0 (0.0) 7 (5.6) F 1.431 0.232 F = Fischer exact
Unavailability of vaccines and distance were the commonest reasons in both
localities for non completion of child’s immunization. Other barriers to immunization in
the urban areas included inconvenient timing of immunization (15.2%) and unaware of
the need for immunization (8.7%) while postponement of vaccination (11.9%),
inconvenient timing of immunization (11.1%), lack of money (9.5%) and unaware of
the need for immunization (6.3%) were the barriers in the rural area.
79 Table 16: Utilization of maternal health services in public health facilities
Period Urban Rural Frequency Frequency
ANC Delivery PNC ANC Delivery PNC
Jan - Mar 2007 930 102 73 191 18 0
Apr - Jun 2007 1278 167 76 296 36 4
Jul - Sep 2007 1178 198 68 366 41 4
Oct - Dec 2007 1523 201 81 303 51 6
Jan - Mar 2008 1320 229 120 300 43 8
Apr - Jun 2008 1113 214 90 332 29 5
Jul - Sep 2008 1576 215 167 332 53 2
Oct – Dec 2008 1320 236 125 317 40 1
Total 10238 1562 2437 311
Difference between ANC & delivery 8676 2126 % difference in 85% 87% delivery
A two-year review of maternal health services in the public health facilities
revealed that ANC attendance did not show any consistent pattern. In the urban area,
ANC attendance fluctuated and peaked twice in Oct-Dec 2007 and Jul-Sept 2008.
Delivery services increased from 102 to 236 over the period though not consistently. It
80 declined in the second and third quarters of 2008. Post natal care attendance also increased over the period and peaked in Jul-Sept 2008 but declined the next quarter.
In the rural area maternal health care service utilization also did not show any consistent pattern. ANC attendance peaked in Jul-Sept 2007 and declined subsequently, while delivery services peaked in Oct-Dec, 2007 and Jul-Sept 2008 with interludes of declines. Post natal care attendance was generally low, increasing gradually to 8 in Jan-
Mar, 2008 and declined consistently since them. Furthermore, from clinic records only
15% of deliveries took place in the urban area by the mothers who attended ANC there, while 13% of deliveries took place in the rural public health facilities by mothers who attended ANC in that locality.
81 Table 17: Proportion of deliveries and PNC visits in the public health facilities
Period Urban Rural Frequency Frequency
% Deliveries % PNC Visits % Deliveries % PNC among ANC among among ANC Visits among Attendees Deliveries Attendees Deliveries Jan - Mar 2007 11.0 71.6 9.4 0.0
Apr - Jun 2007 13.1 45.5 12.2 11.1
Jul - Sep 2007 16.8 34.3 11.2 9.8
Oct - Dec 2007 13.2 40.3 16.8 11.8
Jan - Mar 2008 17.3 52.4 14.3 18.6
Apr - Jun 2008 19.2 42.1 8.7 17.2
Jul - Sep 2008 13.6 77.7 16.0 3.8
Oct – Dec 2008 17.9 53.0 12.6 2.5
Utilization of maternity services in the urban locality fluctuated over the period,
peaked in April-June 2008 and was least utilized in Jan-Mar 2007. While post natal care
utilization was highest in Jul-Sept 2008 and was least in Jul-Sept, 2007. In the rural
area, maternity service utilization was highest in Oct-Dec, 2007 and was least in April-
June 2008, while post natal care utilization peaked in Jan-Mar 2008 and was least in the
first quarter of 2007.
82 Table 18: Percentage DPT3 Immunization coverage by wards in both communities
2007 Nnewi North Dunukofia Wards Target No of % Wards Target No of % pop 0-5 children Coverage pop 0-5 children Coverage yrs immunized yrs immunized Umudim I 5125 205 4.0 Ukpo I 929 152 16.4 Umudim II 7700 202 2.6 Ukpo II 1238 118 9.5 Nnewichi I 6418 1030 16.0 Ifitedunu I 743 251 34.0 Nnewichi II 3346 398 12.0 Ifitedunu II 955 103 11.0
Total 22589 1835 8.12 3865 624 15.2
2008 Nnewi North Dunukofia
Wards Target No of % Wards Target No of % pop 0-5 children Coverage pop 0-5 children Coverage yrs immunized yrs immunized Umudim I 5125 313 6.1 Ukpo I 929 213 23.0 Umudim II 7700 291 4.0 Ukpo II 1238 211 17.0 Nnewichi I 6418 1539 24.0 Ifitedunu I 743 124 17.0 Nnewichi II 3346 436 13.0 Ifitedunu II 955 107 11.2
Total 22589 2579 11.4 3865 655 16.0
A two year retrospective review of records for DPT3 immunization coverage
from the public health facilities reveals that percentage coverage was 8.1% for 2007 and
then increased to 11.4% in 2008 in Nnewi North LGA, while the percentage coverages
of the four (4) wards which offer immunization services in Dunukofia LGA were 15.2%
for 2007 and 16.0% for 2008. There was better percentage immunization coverage in
the rural area than in the urban area for DPT3 for this period.
83 Table 19: Percentage measles immunization coverage by wards in both communities
2007 Nnewi North Dunukofia Wards Target No of % Wards Target No of % pop 0-5 children Coverage pop 0-5 children Coverage yrs immunized yrs immunized Umudim I 5125 232 4.5 Ukpo I 929 141 15.1 Umudim II 7700 244 3.2 Ukpo II 1238 106 8.6 Nnewichi I 6418 888 14.0 Ifitedunu I 743 160 22.0 Nnewichi II 3346 513 15.0 Ifitedunu II 955 129 14.0
Total 22589 1877 8.3 3865 536 13.9
2008 Nnewi North Dunukofia Wards Target No of % Wards Target No of children % pop 0-5 children Coverage pop 0-5 immunized Coverage yrs immunized yrs Umudim I 5269 358 6.8 Ukpo I 955 192 20.1 Umudim II 7916 302 43.8 Ukpo II 1273 194 15.2 Nnewichi I 6598 998 15.1 Ifitedunu I 764 97 12.7 Nnewichi II 3440 504 15.0 Ifitedunu II 982 93 9.5
Total 23223 2162 9.3 3974 576 14.5
For measles vaccine, 8.3% and 9.3% immunization coverage were recorded for
2007 and 2008 respectively in the urban areas, while 13.9% of children were
immunized in 2007 and 14.5% also immunized with measles vaccine in 2008 in the
rural area. This also shows better immunization coverage in the rural communities.
84 18
16
14
12
10
8 URBAN RURAL 6
4 % IMMUNIZATION COVERAGE % IMMUNIZATION 2
0 2007 2008 YEAR
Fig 1: Percent DPT3 immunization coverage in urban and rural areas
Figure 1 shows the percent DPT3 immunization coverage in urban and rural areas. In the urban area in 2007 it was 8.1% but rose to 11.4% in 2008, also in the rural area the coverage in 2007 was 15.2% and increased to 16.2% in 2008. Although the increases were insignificant, the figure shows that the DPT3 immunization coverage was higher in the rural area than the urban area.
85
16
14
12
10
8 URBAN 6 RURAL 4
% IMMUNIZATION COVERAGE % IMMUNIZATION 2
0 2007 2008 YEAR
Fig 2: Percent Measles immunization coverage in urban and rural areas
As in Figure 1, there was minimal increase of measles immunization coverage in the urban area from 8.3% in 2007 to 9.3% in 2008. In the rural area, the coverage also increased from 13.9% in 2007 to 14.5% in 2008. This shows that immunization of children was higher in the rural areas.
86 Table 20: Drop out rate of immunization in the public health facilities for 2007 - 2008
Vaccine Urban Rural
Frequency Dropout Rate Frequency Dropout Rate (%) (%) OPV0 4770 23.7 1207 -8.9
OPV3 3641 1315
DPT1 3975 -10.6 1238 0.3
DPT3 4395 1234
HBV1 4461 22.0 1391 17.8
HBV3 3480 1143
Dropout rate
DPT1 – DPT3 x 100 = % point difference between successive doses of a vaccine (expressed as a % of the 1st dose). DPT1
There were significant dropout rates for OPV and HBV of more than 20% in the urban area, while there was an 18% dropout rate for HBV in the rural area. Also of significance, is a favorable completion of immunization in children; -10.6% for DPT in the urban areas and -8.9% for OPV in the rural areas showing that the respondents in these localities were more serious in taking their children for these two immunizations.
87 CHAPTER FIVE
DISCUSSION
The mean ages of the respondents in both communities did not differ significantly. Women in the urban area were more educated and the fertility rate of the rural women was higher and also had more surviving children. The National Health and
Demographic survey of 2003 also reported higher fertility rate among the rural households than the urban households.30
Knowledge and perception of maternal and child health services in both localities were quite high although higher in the urban than in the rural. This is because most women studied in both localities had at least primary education except for a few of them in the rural area. Also, most of them were media exposed as majority of them had either radio or television or both. Studies have demonstrated a relationship between knowledge of maternal health services, literacy and access to media. It has been shown that literacy and access to mass media were directly associated with good knowledge and perception of maternal and child health service utilization and indirectly with actual utilization of such services.6,7
Most of the mothers attended ANC in their last confinement reporting ante natal care utilization rate of more than 90% which is higher than the national average ANC utilization rate of 59%. This is quite high compared to South Africa where ANC utilization rate was reported to be in the range of 66% and 78%.2,17 In Kenya, a comparable ANC utilization rate of 92% was reported. Previous studies also revealed
88 high ANC service utilization in south east Nigeria. In Oji River LGA in Enugu State
96% ANC service utilization rate was reported, while UNFPA reported 89% and 96.8% for Anambra and Abia States respectively in 2004.4,5 Most mothers studied also visited a health facility for antenatal consultation; private hospital, public health facility and maternity homes. Utilization of private hospitals for ANC was less in the rural areas. A study of ANC utilization in Enugu State also showed that women in rural area were less likely to utilize private hospitals for ANC services, although in comparison with this study the proportion of women in the rural communities utilizing antenatal care services was relatively low. Only about 30% of the women utilized public health care facilities compared to 59% reported by Uzochukwu et al in Oji River LGA. 5 Private health care facilities are known to provide convenience and good interpersonal relationship between client and provider which is often lacking in most public health care facilities.
Most of the women in both localities visited ANC clinic for the first time during the last pregnancy in the first trimester. In India only 33% of women commenced their
ANC visits within the first trimester. Early booking for ANC allows early detection and management of potential risks to the baby and mother during pregnancy and labour, resulting in better pregnancy outcome. Also, average ANC attendance was high and more than the recommended number of visits for the focused ANC, which is 4 times.
Facility delivery was also high among the women. Only 3.3% and 5.0% of women in the rural areas were delivered by either a TBA or delivered at home respectively.
However, non facility delivery rate in this study was lower compared to the proportion
89 reported by Uzochukwu et al in 2004 5 and also less than the national average of 60%.4
It is even lower compared to the rate reported in Iraq and India. In India about half of the women delivered at home without professional medical supervision.1,3 Also, non facility delivery was higher in the rural communities as more delivered either at home or by a TBA. Most women in the rural area delivered in a maternity usually manned by a nurse/midwife or public health facilities which in this case were health centers. The maternities though mostly owned by nurse/midwifes were often staffed with auxiliary nurses who have limited obstetrics skills. Most deliveries in the urban area took place in private health care facilities and were more likely to be attended to by skilled birth attendants, because almost all of them are owned by qualified doctors.
Post natal care utilization like the ANC and deliveries also was high among the respondents. Most women visited to ascertain the state of their health and for the immunization of their babies, while fewer did so because the midwife instructed them to do so or for family planning. More than 70% of the women in both localities had ever immunized their last child against any of the vaccine preventable diseases, although only about a half of them had child health cards. Immunization coverage rates both by self-report and using the child health card for specific antigens was between 97-100% for the urban children and ranged between 75% and 97% for those in the rural areas.
However, Vitamin A supplementation was lower in rural communities 75.1% as against
97.8% in the urban. This was however higher than the national average of 69% reported in 2003 Demographic and Health Survey.30 Also, when compared with findings in Asia
90 it was also high.26 Most of the children in both localities received BCG vaccine, while the vaccine with the least coverage was yellow fever for the urban children and HBV for the rural children.
Barriers to maternal health service utilization as observed in this study include physical and economic access to care, attitude of care providers, husband’s opinion, long waiting time, and unavailability of drugs. In addition to the earlier mentioned barriers patient’s personal decision, failure to plan for postnatal consultation and dislike for health facility were other reasons mentioned for non utilization of postnatal care services. For immunization, unavailability of vaccines, distance, inconvenient timing, ignorance, postponement and lack of funds were among the reasons for failure to immunize their children. Previous studies have demonstrated a relationship between these barriers and optimal utilization of MCH services.7,9,10,21
Inaccessibility and nonavailability to maternal and child health care services to women needing such services is a well known barrier to MCH service utilization in developing countries. The poor and those in the rural communities are more significantly affected. Uzochukwu et al reported that women were more likely to patronize health facilities closest to them.12 In Ghana distance, cost of service and income were also reported as factors influencing maternal service utilization.9
Interventions to improve physical accessibility to health centers had been shown to improve health care service utilization.43 However, increasing accessibility to maternal and child health care services does not always translate to increased utilization as
91 reported in a study in Eastern Nigeria,12 as patients are not likely to visit health care facilities where services are perceived as low quality. Determinants of patients’ perception of quality of care include availability of services and drugs, waiting time and attitude of health care workers. Some of the mothers who did not utilize maternal and child health services attributed it to long waiting time, unavailability of drugs or vaccines and poor attitude or unavailability of the health care workers.
The study also revealed the implications of men’s role in reproductive health.
Partners’ decision was a major reason for non facility delivery. This is because of the dominant role men play in household decision and gender inequality prevalent in our setting. Majority of women in sub Saharan Africa are not empowered and therefore cannot take decisions on their own even on issue concerning their health.
Most women in both localities had at least primary education, were media- exposed and demonstrated good knowledge and perception of maternal health care services, consequently health care utilization was high. High maternal health care service utilization had been reported among women who are educated and media exposed.2,9 Their level of knowledge of MCH services shows that the women had good access to MCH service information, although their sources of information were not assessed. Women who are knowledgeable about MCH services are more likely to utilize it.
Although, women in both areas demonstrated good knowledge and perception of maternal and child health services those in the urban area were better informed than
92 their rural counterparts, particularly on issues pertaining to maternal health. It was also observed that all the women in the urban area had formal education unlike in the rural areas where a few did not have any form of formal education, thus they were less likely to appreciate maternal and child health issues. The huge attention paid to both routine immunization and NIPDs particularly through media and community mobilization must have accounted for relatively high knowledge of child health in both areas.
MCH service utilization was high in both urban and rural areas; however pattern of utilization differed significantly in both localities. Women in the urban areas were more likely to patronize private hospitals, while their rural counterparts were more likely to visit maternity homes either for ANC or for delivery. The increased patronage of private hospitals is not unconnected with the increased role of private sector in healthcare delivery in South Eastern Nigeria because they appear more convenient and less time consuming. Also, most of the private health care facilities are located in the urban areas where they believe their services are better patronized.9 Maternity homes though privately owned provided cheaper and convenient alternative for the rural women. Also, women in the rural areas were more likely to patronize a TBA or deliver at home, while attendance by a skilled birth attendant was more likely in the urban.6 The implication of this is that rural women not only lack access to quality maternal health care services, they are also failing in a key indicator for measuring Millennium
Development Goal (MDG 5).
93 Distance was a major barrier limiting utilization of maternal and child health care services in both localities but more so for the rural women. Although, there was no significant difference in the relative distance of health facility from place of residence in both areas, the fact that most urban households had more cars and also have ready access to transportation invariably reduces the time and cost of accessing the health care facilities. Consequently, the effect of distance was accentuated by lack of functional personal means of mobility and ready access to transportation in the rural area resulting in increased cost of accessing care; both direct and indirect cost.
Also, more women in the rural area were less likely to decide on the place for delivery on their own than their urban counterparts. This might be because women in the urban area were more economically empowered than those in the rural area. Having better education, more access to media and ownership of household items including personal means of mobility. Also, they were more knowledgeable on MCH health services, thus are more likely to be involved in the household decision making process particularly maternal and child health.2,34 Although, more urban women were involved in making household decisions, spousal influence was the commonest reason for failing to deliver in a health facility. Inability of a woman to take decisions concerning her health has been shown to negatively impact on their utilization of health care services.
Utilization of post natal care services were primarily influenced by different factors. For the women in the urban area it was to make sure that they were back to normal, while the rural women were more likely to visit either because the midwife said so or for
94 family planning. However, in both urban and rural areas, immunization was an important reason for attending postnatal consultation.
Review of the public health care facilities records in both localities revealed further the disparity in maternal health care service utilization. Facilities in the urban areas reported higher maternal care service utilization. However, the higher population of the urban area might have accounted for greater ANC service utilization. But considering the proportion of deliveries by ANC attendees and proportion of PNC attendance by deliveries it was obvious that most of the women who utilized ANC services in the public health care facilities did not deliver there nor attended post natal consultation after delivery. It was also obvious that PNC service utilization was on the decline for the period under review.
For uptake of immunization services, DPT3 and measles immunization coverage were more in the rural than urban areas. Women in the urban area were more likely to patronize private hospitals, while their rural counterparts were more likely to visit public health facilities. Patronage of the private health facilities is high because they appear less time consuming and is more convenient. Also most of the private health facilities are located in the urban areas where they believe their services are better patronized.9 Research carried out in India showed that the coverage of various vaccines was higher among the urban than among the rural population. Of the eligible children aged above nine months, 63.3% of urban children and only 14.5% of rural children were fully vaccinated.44,45 Similar Nigerian based studies also indicate that children in
95 rural areas are more disadvantaged than those in the urban areas to be fully immunized.25,26 This is quite different from this study where children from the rural area had higher percentage immunization coverage for DPT3 and measles.
Vaccination dropout rate was reported in both urban and rural areas, but for different vaccines. There was an improvement in dropout rate for DPT for the urban area; –10.6% than for the rural, 0.3%. This contrast a previous project which assessed immunization coverage in three states of the federation: an inspection of dropout rates
27 from DPT1 to DPT3 indicates that completion of coverage is weak in all three states.
For this study the strong completion rate is likely due to better mothers’ knowledge, perception and attitude towards the vaccination of their children and also pattern of vaccines supply in both localities. The high HBV3 and OPV3 drop-out rates of between
17% to 24% spell bad news for the health of young children and present a challenge for local health delivery system. Although high, it is lower than 37.2% reported in Ilorin.46
The figures show that the mothers had been in contact with healthcare system because their children had received a dose of HBV and OPV. They did not, however, return with their children to complete the 3-dose series of the vaccines. This suggests that the caregivers were either dissatisfied with the services or were not even aware that courses of these vaccines were needed; particularly for HBV which had high drop-out rates in both the urban and rural areas. Also, at the facility level, pressures to achieve targets may result in an upward bias in the reporting, or a lack of interest in record keeping and reporting may lead to underestimates of coverage.47 These figures pinpoint deficiencies
96 in the quality of immunization services provided and can spark measures to correct the problems and improve immunization coverage within the current infrastructure at minimal cost.
97 CONCLUSION
This study investigated the comparative study of utilization of maternal and child health services in rural and urban communities in Anambra State. Maternal health services begin at the time of conception and include pre-natal, intra-natal and post-natal care while immunization practices indicators include percent of children that received any childhood vaccine or percent that have received all the required doses of the various vaccines by 0-23 months. Utilization of MCH services was adequate due to mothers’ knowledge, perception of MCH services in mothers of children aged 0-59 months.
Urban dwellers demonstrated better knowledge of maternal and child health care service utilization. Factors that influenced MCH utilization included distance of MCH services, long waiting time, poor attitude of staff, unavailability of drugs, socio- economic status of the respondents, no ready means of transportation and who takes decision on the usage of MCH services and varied in both areas. Health facility records also confirmed better service utilization by mothers in the urban area than those in the rural.
Thus, it can be concluded that women in rural Anambra State unlike their urban counterparts do not access quality maternal and child healthcare due to their poor socioeconomic status and level of knowledge of maternal and child healthcare. Also, since the immunization coverage is low in both urban and rural communities, the likelihood of attaining the MDGs 4 and 5 by 2015 is low.
98 RECOMMENDATIONS
The recommendations for optimal national scaling up of MCH services amongst women and children need a multisectoral approach with coordination and commitment from the government, donor agencies and communities. Their cohesive action is needed because the implementation of MCH programs involves steps beyond the reach of the local communities. The following considerations are essential for improving MCH utilization;
Considering the positive correlation observed between educational status and
maternal service utilization among the women studied, measures should be taken
to improve female education and income earning ability to enable them take
decisions on issues pertaining to their health.
Men should be educated further through the use of mass media on their role on
maternal and child health so as to enable them to positively impact on the health
status of their wives and children.
Efforts to improve maternal service utilization should focus both on increasing
accessibility and improving quality of service delivery by the provision of skilled
birth attendants particularly in the rural areas, and also ensure their
sustainability.
99 Government policies should put into consideration strategies which will help in
mobilizing the populace for active participation in their own healthcare including
health education of peers and neighbours.
Reinforced health education should be given to the mothers on the importance
and benefits of the Child health card by healthcare providers.
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107 APPENDIX II
INFORMED CONSENT FORM Dear Madam, I am Dr. Nonye B. Egenti; a resident doctor with the Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi.
Purpose of the study We are conducting this study to determine the level and pattern of utilization of MCH services. We also want to find out your knowledge and perception of MCH services. No payments will be made to you for participating in this study, however findings obtained from this project will form a basis for evolving solution geared towards improving MCH services. This will go a long way to reduce ill health, disability and deaths in mothers and children.
Procedure The procedure will involve asking you to express your views in a form called questionnaire. We will assist you to fill the form. It will take about 20 minutes to fill the form. In the form we will like to find out what you know and perceive of MCH services. Your honest responses to the questions will help us understand better issues relating to the utilization of MCH services in urban and rural communities in Anambra State.
Participation You are free to either participate or not in the study. You also have the right to withdraw at anytime if you choose to. We will however, appreciate your cooperation in responding to the survey and taking part in the study.
108 Confidentiality I wish to assure you that nobody will know what you have written in your form. Every information obtained from you will be a secret and will not be divulged to anyone under any circumstance whatsoever.
Hazard/Benefit There are no known hazards involved in participating in the study. However, findings from this study will be used to plan for better healthcare for women of child bearing age and children aged 0–59 months in our communities.
Consent Now that this study has been well explained to me and I fully understand the study purpose and process, I will be willing to take part in the study.
------Participant’s Signature Witness’ Signature
109 APPENDIX III
QUESTIONNAIRE UTILIZATION OF MATERNAL AND CHILD HEALTH SERVICES IN AN URBAN AND RURAL COMMUNITY IN ANAMBRA STATE
Dear respondent, we are interested in your knowledge, attitude and utilization of maternal and child health services. Your view on this issue is very important and we will appreciate if you will assist us by providing relevant information. We assure you that information provided will be strictly confidential. However, participation is voluntary and you don’t have to answer any question you do not feel like answering. Also, you can stop the interview any time you wish. A. RESPONDENTS PERSONAL INFORMATION. Name of Ward______Local Government Area ______1. Age as at last birthday (in years)…………………………. 2. Marital status: single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed [ ] 3. Educational status: No formal education [ ] Primary [ ] Secondary [ ] Tertiary [ ] 4. Educational status of the spouse: Nil [ ] Primary [ ] Secondary [ ] Tertiary[ ] 5. State your exact job in the workplace………………………………… 6. Specify the job of your spouse……………………………………… 7. Number of pregnancies……………………………………………… 8. Number of surviving children………………………………………. 9. Who is the decision maker for household on health issues? a. Self [ ] b. Spouse [ ] c. Both [ ]
110 d. Mother-In law [ ] e. Others (Specify)………………………………… 10. Religion of household a. Roman Catholic [ ] b. Anglican [ ] c. Pentecostal [ ] d. Islam [ ] e. Trado-Religion [ ] 11. How far is the nearest health facility from your place of residence? 0-5km [ ] >5km [ ] 12. What is your main personal means of mobility? a. [ ] Car b. [ ] Motorcycle c. [ ] Bicycle d. [ ] None e. Others (specify) 13. Do you have any of this following household item? a. [ ] Cable/Satellite Television b. [ ] Television without cable/satellite c. [ ] Radio d. [ ] Telephone e. [ ] None f. Others (specify)…………………………….. B. Knowledge and Perception of Maternal and child health services 14. Do you know that pregnant woman should; 14.1 Make at least three ANC visits before delivery? Yes [ ] No [ ] Don’t Know [ ] 14.2 Start ANC within the first 3 months of pregnancy? Yes [ ]No[ ]Don’t Know [ ]
111 14.3 Be delivered by a skilled attendant (doctor or midwife)? Yes [ ] No [ ] Don’t Know [ ] 14.4 Visit a health facility 6 weeks after delivery for check up? Yes [ ] No [ ] Don’t Know [ ] 14.5 Every child should be immunized against all the VPDs? Yes [ ] No [ ] Don’t Know [ ] 15. Do you think that; 15.1 The timing of starting ANC is not important? Yes [ ] No [ ] Don’t Know [ ] 15.2 ANC attendance is important to detect problems in pregnancy and to correct them?Yes [ ] No [ ] Don’t Know [ ] 15.3 Pregnant women should deliver at only health facilities where there is a doctor or midwife? Yes [ ] No [ ] Don’t Know [ ] 15.4 Visit to health facility after 6 weeks of delivery can help mothers plan their family? Yes [ ] No [ ] Don’t Know [ ]
15.5 Immunization protects children from major killer diseases? Yes [ ] No [ ] Don’t Know [ ]
C. Utilization of MCH 16. Did you attend ANC (at least) during your last pregnancy? Yes [ ] No [ ] (if no skip to) 17. If yes, where? 1. [ ] Public health facility 2. [ ] Private health facility 3. [ ] Maternity 4. [ ] TBA 1. Others (specify)…………………………………….. 18. At what month of the pregnancy did you start attending ANC? ...... 19. How many ANC visits did you make before delivery? …………………
112 20. If no, why? 1. [ ] Cannot afford cost of services 2. [ ] Health facility far 3. [ ] Poor attitude of Staff 4. [ ] Long waiting time 5. [ ] Drugs not available 21. Where did you deliver during your last pregnancy? 1. [ ] Public health facility 2. [ ] Private health facility 3. [ ] Maternity 4. [ ] TBA 5. [ ] Home 6. Others (specify)…………………………… 22. Was the delivery attended to by a doctor or midwife? Yes [ ] No [ ] DNK [ ] 23. Who decided choice of place of delivery? 1. [ ] Myself 2. [ ] Partner 3. [ ] Both 4. [ ] Mother 5. [ ] Mother-in-law 6. Others (specify)…………………………………………… 24. If you did not deliver in a health facility why? 1. [ ] Could not afford 2. [ ] Health facility to far 3. [ ] No ready means of transport 4. [ ] Husband’s decision 5. [ ] My decision
113 6. [ ] Not planned 7. [ ] Don’t like facility 8. Others (specify)……………………………….. 25. Did you go back to the health worker 6 weeks after delivery? Yes [ ] No [ ] 26. If yes, why? 1. [ ] Because was ill 2. [ ] Because the baby needed it’s immunization 3. [ ] Because the midwife had told me I should 4. [ ] Because I wanted to start family planning 5. [ ] Because I wanted to make sure I am back to normal f. Other (specify)………………………. 27. If no, why? 1. [ ] Could not afford 2. [ ] Health facility to far 3. [ ] No ready means of transport 4. [ ] Husband’s decision 5. [ ] My decision 6. [ ] Not planned 7. [ ] Don’t like facility 8. Others (specify)……………………………….. For mothers with children aged between 12-23 months only 28. Was your last child ever immunized? Yes [ ] No [ ] 29. Which of these vaccines has he/she received? [ ] BCG [ ] OPV0 [ ] OPV1 [ ] OPV2 [ ] OPV3 [ ] DPT1 [ ] DPT2 [ ] DPT3 [ ] [ ] HBV1 [ ] HBV2 [ ] HBV3 [ ]
114 [ ] Measles [ ] Yellow Fever [ ] Vitamin A 30. Do you have the immunization card? (Validate immunization by verifying card record if available) [ ] BCG [ ] OPV0 [ ] OPV1 [ ] OPV2 [ ] OPV3 [ ] DPT1 [ ] DPT2 [ ] DPT3 [ ] [ ] HBV1 [ ] HBV2 [ ] HBV3 [ ] [ ] Measles [ ] Yellow Fever [ ] Vitamin A 31. Why did your child not complete his/her immunization? (for children with incomplete immunization status) a. [ ] Vaccine not available b. [ ] Place of immunization too far c. [ ] Unaware of the need for immunization d. [ ] Fear of side reactions e. [ ] Vaccinator absent f. [ ] Postponed until next time g. [ ] Lack of money h. [ ] Time of immunization not convenient i. [ ] Lack of confidence and lack of trust j. [ ] Vaccine providers are not friendly k. [ ] Long waiting times by mothers l. Others (specify) ______
115 APPENDIX VII
The 21 LGAs IN ANAMBRA STATE, SOUTH EASTERN NIGERIA: GROUPED AS URBAN OR RURAL
S/NO URBAN S/NO RURAL 1 Awka South 1 Awka North 2 Idemili North 2 Njikoka 3 Onitsha North 3 Idemili South 4 Onitsha South 4 Orumba North 5 Ihiala 5 Orumba South 6 Nnewi North 6 Ekwusigo 7 Nnewi South 7 Ogbaru 8 Ayamelum 9 Anambra East 10 Anambra West 11 Anaocha 12 Oyi 13 Dunukofia 14 Aguata
Courtesy of National Population commission, Awka, Nigeria
116 APPENDIX VIII
THE TEN WARDS IN NNEWI NORTH LGA AND THEIR TARGET POPULATIONS. S/NO WARDS TARGET POPULATION 1 Otolo I 6,783 2 Otolo II 1,227 3 Otolo III 1,808 4 Uruagu I 6,382 5 Uruagu II 4,587 6 Uruagu III 2,181 7 Umudim I 7,865 8 Umudim II 11,819 9 Nnewichi I 1,961 10 Nnewichi II 5,137 TOTAL 49,750
THE FOURTEEN WARDS IN DUNUKOFIA LGA AND THEIR TARGET POPULATIONS
S/NO WARDS TARGET POPULATION 1 Ukpo I 1,838 2 Ukpo II 2,457 3 Ukpo III 2,439 4 Ifitedunu I 1,472 5 Ifitedunu II 1,893 6 Ifitedunu III 2,207 7 Ukwulu I 1,430 8 Ukwulu II 2,377 9 Umudioka I 2,439 10 Umudioka II 4,288 11 Umunnachi 1 2,808 12 Umunnachi 1I 4,232 13 Nawgu I 1,514 14 Nawgu II 2,314 TOTAL 33,703
Courtesy of National Programme on Immunization in Collaboration with WHO, Awka, Nigeria 2008.
117 APPENDIX IX LIST OF HEALTH FACILITIES OFFERING ROUTINE MCH SERVICES IN NNEWI NORTH LGA.
S/NO NAME OF HEALTH FACILITY TYPE OF OWNERSHIP 1 PHC Okpunor Otolo PUBLIC 2 H/C Umuanuka “ “ 3 PHC Ndiakwu “ “ 4 H/C Ndimgbu “ “ 5 H/C Okofia “ “ 6 PHC Umuenem “ “ 7 PHC Ezekwuabor “ “ 8 H/C Uruagu “ “ 9 H/C Obiagu “ “ 10 H/C Ndiezenwankwo “ “ 11 H/C Akaboukwu “ “ 12 PHC Edoji “ “ 13 NAUTH, Nnewi “ “ 14 H/C Umumejiaku “ “ 15 PHC Inyaba “ “ 16 PHC Uru “ “ 17 H/C Eme-Court “ “ 18 PHC Okpuno-egbu “ “ 19 H/C Akanmili “ “ 20 H/C Obiuno “ “ 21 H/C Okpuno-Nnewichi “ “ 22 H/C Abubor “ “ 23 Nnewi Diocesan Hospital MISSION 24 Family Care Maternity PRIVATE 25 Chidera Hospital “ “ 26 Obioma specialist hospital “ “ 27 Divine Care Specialist Hospital “ “ 28 Chicason Mannyon Sp Hospital “ “ 29 Foundation Hospital “ “ 30 Ngozi Maternity Uruagu “ “ 31 Madonna Hospital “ “ 32 Ngozi Maternity Inyaba “ “ 33 Life Specialist Hospital “ “ 34 Felix Okolo Memorial Hospital “ “ 35 Immaculate Heart Hospital MISSION
Courtesy of Health Department, Nnewi North LGA Headquarters, Nnewi, Anambra State.
118 LIST OF HEALTH FACILITIES OFFERING MCH SERVICES IN DUNUKOFIA LGA
S/NO NAME OF HEALTH FACILITY TYPE OF OWNERSHIP 1 PHC Unit NAUTH Nnewi PUBLIC 2 PHC, Ukpo “ “ 3 PHC, Umunnachi “ “ 4 PHC, Ukwulu “ “ 5 PHC, Ifitedunu “ “ 6 PHC, Umudioka “ “ 7 Health post Ifitedunu “ “ 8 Health post Nawgu “ “ 9 Health post Umudioka “ “ 10 Health post Umunnachi “ “ 11 Health post Ukpo “ “ 12 Chinaza Hospital, Umunnachi PRIVATE
Courtesy of National Programme on Immunization Office Dunukofia LGA Headquarters, Ukpo, Anambra State.
119 APPENDIX X
NPI ROUTINE IMMUNIZATION SCHEDULE Vaccine No of Age Minimum interval Route Dose Site Doses between doses BCG 1 At birth or as soon as - Intradermal 0.05ml Upper left possible after birth arm OPV 4 At birth and at 6,10 4 weeks Oral 2 drops Mouth and 14 weeks of age DPT 3 At 6,10 and 14 weeks 4 weeks Intramuscular 0.05ml Anterior of age (IM) part of thigh HBV 3 At birth, 6 and 14 4 weeks 0.05ml Anterior weeks IM part of thigh Measles 1 At 9 months of age - 0.05ml Upper left Subcut arm Vitamin 2 At 9 months and 15 6 months 100,000 IU & Mouth A months of age Oral 200,000 IU Yellow 1 9 months - IM 0.05ml Upper fever right arm
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