DETERMINANTS OF KNOWLEDGE AND UPTAKE OF MATERNAL

SERVICES AMONG MOTHERS OF UNDER-FIVES IN BENIN CITY.

BY

ADEGBOYE VICTORY OGBOJOSHUKU MED1105669

BEING A ONE YEAR PROJECT PRESENTED TO THE DEPARTMENT

OF COMMUNITY HEALTH, COLLEGE OF MEDINICE, UNIVERSITY

OF BENIN, BENINCITY, EDO STATE, NIGERIA.

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

AWARDS OF BACHELOR IN MEDICINE AND BACHELOR IN

SURGERY (MBBS) DEGREE IN UNIVERSITY OF BENIN, BENIN CITY.

JUNE 2017
DEFINITION OF TERMS

Maternal Health: refers to the health of women during pregnancy, childbirth and the postpartum

period.

Antenatal care: refers to the care given to the mother in an hospital during the period of

pregnancy.

Mortality: simply refers to death.

LIST OF ABBREVIATIONS

WHO: World Health Organization

MDG: Millennium Development Goals

MCH: Maternal and Child Health

BI: Bamako Initiative

MHCS: Maternal Healthcare Services

TBAs: Traditional Birth Attendants

ANC: Antenatal Care

HIV: Human Immunodeficiency Virus

IPTp: Intermittent Preventive Treatment of Malaria during Pregnancy

DHS: Demographic And Health Survey

 CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND

While motherhood is often a positive and fulfilling experience, for too many women it is associated

with suffering, ill-health and even death. The major direct causes of maternal morbidity and

mortality include haemorrhage, infection, high blood pressure, unsafe abortion, and obstructed

labour.1

When the Safe Motherhood Initiative was launched in 1987, like the rest of Africa, Nigeria got

deeply involved. Nobody expected miracles overnight, nor did anyone expect disaster of such

immensity. Sadly, there is hard evidence to demonstrate that much of the good ideas, the good

intentions, and the good work done then have failed to come to fruition.2

Utilization of maternal health services is associated with improved maternal and neonatal health

outcomes. Considering global and national interests in the Millennium Development Goal and

Nigeria's high level of maternal mortality, understanding the factors affecting maternal health use

is crucial.3 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.4

With such huge poverty level, the outcome was as described by the Nigeria Population

Commission in its Nigeria demographic and health survey (DHS) report which shows that only

64% of pregnant women in Nigeria access antenatal services, and just 35% give birth in a health

facility while only 39% of birth are delivered by skilled birth attendant. Most women in Nigeria

live below the poverty level and lack access to comprehensive antenatal and delivery services.

Infant mortality figure is also staggering; Child mortality rate under age 5years was 143 per 1,000

births in 2010 compared with 5 per 1,000 for United Kingdom.5

Complications of pregnancy and childbirth are a leading cause of maternal morbidities and

mortalities for women of reproductive age (15 49 years) in developing countries. The WHO

estimates that over 500,000 women and girls die from complications of pregnancy and childbirth

each year, worldwide, with approximately 99% of these deaths occurring in developing countries.

With a maternal mortality ratio of 545 deaths per 100,000 live births, Nigeria accounts for about

10% of all maternal deaths, globally, and has the second highest mortality rate in the world, after

India.6Nigeria is a leading contributor to the maternal death figure in sub-Saharan Africa not only

because of the huge- ness of her population but also because of her high maternal mortality ratio.1
Scientific evidence has clearly established the inverse relationship between skilled attendants at

birth and the occurrence of maternal deaths. Thus, the considerable variation in the maternal

mortality estimates between different locations within the same region can be attributed, to a large

degree, to the differences in the availability of and access to modern maternal health services. The

use of maternal health services also contributes to neonatal health outcomes as the health of the

mother and the new- born is closely linked.1

Improved maternal and neonatal outcomes have been associated with utilization of maternal

healthcare services (MHCS). Studies have shown that the majority of maternal deaths and

disabilities can be prevented through early and timely access to and utilization of quality MHCS.3

Maternal mortality has declined by nearly half since 1990. While progress falls short of achieving

MDG 5 by the 2015 deadline, all regions have made important gains. Globally, the ratio declined

from 400 maternal deaths per 100,000 live births in 1990 to 210 in 2010. Still, meeting the MDG

target of reducing maternal mortality by three-quarters will require accelerated efforts and stronger

political backing for women and children.7

Improving maternal health is also key to achieving MDG 4 of reducing child mortality. Giving

good care to women during pregnancy and at the time of childbirth is crucial not only for saving

womens lives but their babies, too. Births attended by skilled health personnel have increased;

however, disparities in progress within countries and populations groups persist.5

Every year, approximately 600,000 women die of pregnancy-related causes. Ninety- eight percent

of these deaths occur in developing countries, and for every woman who dies, at least 30 others

suffer injuries and, often, permanent disability. Since the adoption of the primary health care

approach in Nigeria in 1979, the three tiers of government (federal, state and local government

levels) have accepted the idea of the need to integrate Traditional Birth Attendants (TBAs) into

PHC system and have consequently initiated TBAs training programmes.8

Several studies have assessed the individual and household determinants of utilization of maternal

services. These studies have not yielded a consistent pattern of relationships between service

utilization and individual and household predictors. In some cases, even when a strong association

has been reported, such as in the case of the positive relationship between education and the use

of skilled health attendants at birth, the extent and nature of the relationship are not uniform across

social settings.2

Regular medical checkup during pregnancy is important to reduce the risk of illness and death for

the mother and child during pregnancy and delivery. In Nigeria, the Sentinel Survey of the National

Population Programme Baseline Report of 2007 shows that about 48 percent of the women

reported that they saw somebody for antenatal care. The report further shows that only 42% of the

rural women received antenatal care from doctors. According to that report the use of Traditional

Birth Attendants (TBAs) is highest in the South-South geopolitical zone of the country.

Concerning maternal and child health-care services, report indicate that the use of these services
is unacceptably low. Other studies have shown that the utilization of available modern maternal

health services is very low in rural Nigeria.9

International organizations and individual governments have recognized the severity of the

problem and have made commitments to reduce the number of maternal deaths globally.

Millennium Development Goal 5 (MDG 5) calls for national maternal mortality ratios to be

reduced by three-quarters between 1990 and 2015. While this may be an unrealistic target at

present the maternal mortality ratio declined only by an average of 5 per cent between 1990 and

2005 African organizations have committed to work towards achieving it.9

Investing in maternal health is urgent: not only because giving life should not result in death, but

also because women are important economic drivers and their health is critical to long-term,

sustainable economic development in Africa. Furthermore, investing in maternal health is a way

to improve health systems overall, which benefits the entire population of a country.10

Antenatal care (ANC) is the care that a pregnant woman receives while she is pregnant through a

series of consultations with a trained health care provider, i.e., midwives, nurses, and medical

doctors. Considering the important of prenatal care programmes that are designed to deal with

factors that are most likely to be associated with maternal and child health, such programmes are

no doubt widely advocated as a way of alleviating the incidence of low birth weight and avoiding

adverse pregnancy outcomes. Reference to the literature on prenatal services, the rate of maternal

and under-five morbidity and mortality, and trend in under- nutrition, the reductions in child
malnutrition and improvements in related outcomes, maternal health and access to antenatal care

are yet to be reached with regard to the Millennium Development Goals.11,12

Family members of pregnant women as well as the com- munity, have roles to play in ANC

attendance. Their involvement in ANC utilization or otherwise affects use of ANC services.

Families and communities often consider pregnancy as a natural process of life and therefore,

under- estimate the importance of ANC. Misunderstandings, conflict or poor communication

among formal and informal health care providers and with health service seekers may cause low

utilization of ANC services in certain communities. Unprofessional practices, attitudes and

behaviours of ANC providers may further increase the non- utilization of ANC. Unprofessional

conduct may include failure to respect the privacy, confidentiality, and traditional beliefs of the

health seekers.13

Several studies have assessed the individual and household determinants of utilization of maternal

services. These studies have not yielded a consistent pattern of relationships between service

utilization and individual and household predictors. In some cases, even when a strong association

has been reported, such as in the case of the positive relationship between education and the use

of skilled health attendants at birth, the extent and nature of the relationship are not uniform across

social settings. For example, whereas studies in Peru and Guatemala showed that women with
primary level education were more likely to utilize maternal health services compared to those

without any formal education, some studies in Thailand and Bangladesh did not record any

significant difference between the two educational groups. Distances to health services and rural

locations have been generally reported to be strongly and negatively associated with the use of

maternal health services. Some studies conducted in Turkey and southern India, however, did not

show any significant difference in the use of antenatal care between urban and rural women.

Association between age and service utilization has also been inconsistent across studies. Whereas

many studies found a positive correlation between age and the use of skilled attendants at child

birth, others have found a curvilinear relationship. Religion has also shown variable pattern of

association with service utilization, with significant association in some settings but not in some

others. In contrast, parity has been consistently shown to be negatively correlated with the use of

skilled attendants. A number of studies have reported positive association between economic status

and use of medical settings for delivery whereas others have not found such an association.3

While available evidence indicates limited benefit from traditional antenatal care services, focused

antenatal care provides opportunity for early detection of diseases and timely treatment. It also

provides opportunities for preventive health care services such as immunization against neonatal

tetanus, prophylactic treatment of malaria through the use of intermittent presumptive treatment

approach, and HIV counseling and testing. Furthermore, antenatal care exposes pregnant women

to counseling and education about their own health and the care of their children. Thus, antenatal

care may be particularly advantageous in resource-poor developing countries, where health

seeking behavior is inadequate, access to health services is otherwise limited, and most mothers

are poor, illiterate or rural dwellers.2

Factors influencing maternal health services utilization operate at various levels - individual,

household, community and state. Depending on the indicator of maternal health services, the

relevant determinants vary. Effective interventions to promote maternal health service utilization

should target the underlying individual, household, community and policy-level factors. The

interventions should reflect the relative roles of the various underlying factors.2

A major determinant of utilization ofIntermittent Preventive Treatment of Malaria during

Pregnancy (IPTp) among the study population was the knowledge of prophylaxis for malaria

prevention. Uptake of IPTp can be significantly improved in rural areas if backed up with

appropriate health education intervention.14

The major determinants of utilization of maternal health services included educational status and

the average monthly income of the respondents. Services were perceived by more than half of the

respondents to be generally good. There is need for the provision of the minimum service

components of maternal health care services especially postnatal service at the PHC facilities.15
1.3 STATEMENT OF PROBLEM

Factors influencing maternal health services utilization operate at various levels - individual,

household, community and state.2

Affected Populations include high maternal mortality primarily occurring among populations who

have little access to or knowledge about family planning and obstetric care, namely those who are

poor, uneducated, or living in rural areas.

The primary risk factors for poor maternal health include poverty, rural living, lack of access to

family planning and contraception, high fertility rate, lack of access to obstetric care, and poor

quality of care.16

The extremely high rates of maternal mortality and pregnancy related disabilities in our country

have lasting social and economic consequences on both individual families and our nation as a

whole. Children who are left without their mothers are more likely to suffer from illness or

malnutrition and are at an increased risk for early death.17

Maternal health care delivery in Nigeria faces many challenges. These include the lack of

acceptability, accessibility and affordability of existing services as well as poor quality control and

poor regulation of services. Maternal health care is grossly underfunded. The affordability of

maternity care remains a critical issue in Nigeria, as more than two-thirds of citizens live below

the poverty line.18

1.4 JUSTIFICATION

From several studies, numerous factors have been noticed to act as determinants of knowledge and

uptake of maternal services in Nigeria which include individual, household, community and state.

Among studies carried out in developing countries including Nigeria, factors affecting the
knowledge and uptake of maternal health services negatively affect mothers and cause a

tremendous rise in maternal mortality. This negates both the Bamako initiatives (BI) programme

and MDG 5 mission.

Maternal health care delivery in Nigeria faces many challenges. These include the lack of

acceptability, accessibility and affordability of existing services as well as poor quality control and

poor regulation of services. Maternal health care is grossly underfunded. The affordability of

maternity care remains a critical issue in Nigeria, as more than two-thirds of citizens live below

the poverty line.19 This study is going to be done to determine what impact it has on mothers of

under-fives in Benin City, Nigeria. It will help in the approach of all parties involved in the

maternal health sector to properly understand and utilize the maternal health care services for their

benefit. This will reduce the maternal mortality rate and in turn, improve the living conditions for

mother, the child and the community at large.

1.5 AIMS AND OBJECTIVES

1.5.1 GENERAL OBJECTIVE

To assess the determinants of knowledge and uptake of maternal health services among mothers

of under-fives in Benin City with a view of providing recommendation to the appropriate

authorities.

1.5.2 SPECIFIC OBJECTIVES

1. To ascertain the level of knowledge of maternal health care service mothers of under-fives

in Benin City.

2. To identify manner of uptake of maternal health services among mothers of under-fives in

Benin City.

3. To ascertain factors that that determine uptake of maternal health care services among

mothers of under-fives in Benin City.

1.6 RESEARCH QUESTIONS

Research questions for this study include:

1. What knowledge do mothers of under-fives in Benin City have about maternal health

services?

2. What maternal health services do mothers of under-fives in Benin City participate in?

3. What factors determine their participation in these maternal health services?

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