University of Nigeria Virtual Library

Serial No.

Author 1

NWAKOBY, B.A.N

Author 2

Author 3

Title

Use of Service s for Maternal Health Care by a Rural Nigerian Community.

Keywords

Description Use of Service s for Maternal Health Care by a Rural Nigerian

Community.

Category

Medical Sciences

Publisher

Publication Date

July, 1990

Signature

Harvard School of Public Health

I

USE OF I BY

ERVICES FOR MATERNAL HEALTH CARE A RURAL N I G E R X ~ COMMUNITY

Boniface Nwakoby

July 1990 ... .

i

desearch Paper NO. 47

Takemi Program in ~nternational Health Harvard School of Public Health

665 Huntington Avenue Boston, MA 02115 (617) 4 3 2 - 0 6 8 6

The pattern an8 determinants of maternal service utilization were studied in a sample of 488 women in n rural Nigerian community. Although 93-49 registered Eor prenatal care in a health institution, only 22% had 'adequate8 prenatal care judged by the criteria of time of initiation of care and the number of prenatal visits. Only 51.2% delivered in a health institution while 48.8% delivered at home mainly under the care of traditional birth attendants. Year by year analysis however showed a decline in the proportion of women del ivered by .t,raditfonal birth attendants f r o m 51.7% in 1987 to 30.2% in 1989. 78.8% had po~tnatal care.

1 Factors found to be most consistently associated with the use of health services were education and occupation of the mother, religion, and occupation of the husband. Maternal age, parity and marital status were not significantly associated with the use of

I services. Distance of the residence of a woman from a heabth

! facility was not significantly associated with the choice of home I I or institutional delivery, but was related to the choice of which

health facility to use when delivery was institutional.

The charges for prenatal and intrapartum care were about the same for private and public sector care. 3 3 . 7 % of the women in the mample had prenatal care in the private sector compared to 61.7% in the pubic sector. For intrapartum care, the figures were 23.6% and 27.6% respectively. The high level of patronage of the pr ivate sector facilitiee raises questions of policy w i t h regards to cost of services in public sector facilities and the role of the private aector in maternal health care in rural communities. Other i~sues that need to be addressed are the desirable 'quantity' of prenatal care, and the place of home delivery and the role of trafitisnal birth attendants in t h e health care of mothers.

1

The benef ioial af d c t s of prenatal, intrapartum and poetnatal I care on the outcome of pregnancy for mother and child have / h e n well documented in many studies. The high level of maternal I mortality in the developing countries has been attributed partly

to the non-availability of services and partly to poor utilization E of services when they are available. This etudy investigates the

utilization by a rural community in Nigeria of maternal. health 3

I mervicee provided hy a public sector health center deemed to be j physically and fi'nancially accessible to the community but

nuboptimally used. It seeks also to identify other sources oh care I

I and to determine the factors that influence the pattern of use.

The high level of maternal mortality in developing countries has become a cause of great concern world wide. The commonly quoted figure is half a million maternal deaths per year of which 99% come as _ram the developing countries (WHO, 1986a; Safe Motherhood Conference, 1987). Deaths related to pregnancy constitute about a quarter of death in women in the child-bearing age in developing countries compared to 1% in developed countries (Royston and Lopez 1987, Boerma 1987). In part6 of West Africa, maternal death rates of over 20 per thqusanc'. births have been reported (Greenwood et al., 1 9 8 7 ) .

Maternal and Child care (MCH) is one of the cardinal components of Primary Health Care. However, while considerable attention has been focused on child care and child survival programs, there has been an inexplicable neglect of the maternal care component (Rosenfield and Maine, 1985; Mahler, 1987)

Access to quality care during pregnancy and delivery seems to be the crucial factor in explaining the disparity in maternal mortality between the developing and the industrialized worlds (Eaine et aZ. 1987). 88% to 00-4; of maternal deaths could be avoided if adequate care were provided (WHO 1986, Faunder, Rosenfield and P i n o t t i 1988). Access Ls believed to increase utilization, and !-ncreased utilization to improve pregnancy outcome.

Utilization of maternal health services can be considered an intermediate variable in the pathway from socio-economic and c'smographic conditions to maternal health status, that ie, a I7roximate determinant' of pregnancy outcome. The proximate determinant framework has been used to clarify the role o' rediating factors on fedtility level (Bongaarts, 1978), and in child survival (Mosley and Chen, 1904). Obermeyer (1988) has discussed the role of service utilization as a proxinaJ:e determinant of maternal, mortality and fertility. The study oi: utilization patterns for maternal health services is therefore seen as an important step in fully understanding the mechanisms responsible forthe note6 discrepancy in pregnancy outcomes between the developed and the developing countries.

Considerable inequities exist in the distribution of health facilities and manpower, aspecially between urban and rural populations. Even in the developed countries, equity in availability of health senices between rural and urban residents remains a major policy issue' (Patrick et al., 1988). In the developing countries, this inequity assumes alarming proportions.

Most facilities and trained manpower are located in the capital cities and urban centem while the rural areas where a groatar percentage of Che population live remain poorly served. In NS.ucl .r ia f o r examplefin a recent study using data from government sourcen, ojo (1990) has shown marked disparity in the distribution of a?-l classes of services and. personnel. .Whereas about 80% 05 the Yigerian population reside in the rural areas, in almost al?: states, 80% or more of the physicians were located in the c a ~ i t a l cities, and the distribution of other personnel including nursss and midwives followed the same pattern.

The Nigerian Federal Government in its Primary Health Care plan (initially Basic Health Services Scheme) adopted a policy of construction of a large number of' primary care faci1XJ:.ies nationwide supplemented by mobile units ( P G N , 1 9 8 1 ) . To enqure quality care, and to involve the.academic and professional health elite in its effort, the government entrusted the running oZtthe first rural comprehensive health centers to university colleges of medicine and their teaching hospitals. In January 1983, the University of Nigeria Teaching Hospital, Enugu opened a 30-he1 comprehensive health certer in Obukpa Town, funded by the Fed-ral Ministry of Health. Maternal and child health care was to fokm. ~n important component of the services provided. This and shn5.lar institutions were to serve as models' for the establishment of comprehensive health centers nation-wide. Obukpa ~ o m p r e h e w i v s Health Center was the first of these model health centers, a x ? so its service performance was of considerable interest.

Obukpa is a town in Nsukka Local Government Area of An~tabra State in the eastern part of Nigeria. Its p o p u l a t i y of 22,290 (projected for 1989 Prom the Nigerian census of 1963 ) is maj-nly rural although thy town lies adjacent to the fairly large University town of Nsukks. Obukpa occupies an area of about 20 u q . kilometers and has a span of about 5 kilometers at its widest. I . : 1 villages in Obukpa are within a distance of less than 5 kilometers from the health center. Its road network is fairly good, but cars are in very short supply: bicycles and motor cycles are the common means of transportation. Literacy is low, and the prirnn~] occupation of the inhabitants is subsistence farming.

The Comprehensive Health Center was the only public-owned health facility within the area and was to serve Obukpa town and the surrounding towns and villages. The center initially provic?ed only out-patient services in maternal and child health (prena5~1 and child welf&re clinics and some family planning activities) ,

No successful censbs has been carried out in Nigeria ninca 1963.

3 -

treatment of common ailments and school health services. In May 1987, a delivery service was started and a physician was employed to take charge of the center which was previously run by p?lbl-ic health nurses and community heath officers.

Services provided were subeyized by. the government to make them affordable to the cor-munity . All children's services were '

free and charges were minimal for adults. Registration for ante- natal care cost approximately NB. 00 (US $2) an3 total official coat for a normal clelivery was N3O. 0 0 (US $ 8 . 5 0 ) .

While prenatal. clinic attendance figures rose steadily (post- natal attendance statistics were not routinely recorded), there was poor response in the use of the facj-lity for intra-partun care. Records of delivery showed only about a third of the num%er registered for pren,;lttal? care in the corresponding period. Thus, a service that has been made available and considered to be physically, and to a large extent financially, accessible to the community was not utilized. The issue then is why accessibility has not generated maximal utilization of intra-partum services.

Hypothesis

Provision of an easily accessible and inexpensive facility within the community may not lead to increased utilization and improved pregnancy outcomes. Distance from a health facility and the financial cost of service to the consumer are not necessarily the important determinants of choice. Factors other than p h ~ ~ i c a l and financial accessibj-lity play a major role in consumer choice o f senrice. Given the aavailability of alternatives; indiv idua. ' .~ in the community make a choice as to which services ta utilize.

Two appro ache^ to the study of the problem seem reletrant. Firstly the alternative, sources of care need to be identifier* and an evaluation of the physical and financial accessibility of available opt'ions needs t o be undertaken to explain prefermce pattern. Secondly, there is also a need to analyze the aocio- demographic characteristics of the clients and the relationship of these characteristics to utilization. Attitudes and be1ief~-which influence choice of service are often determined by mcio- demographic factors.

Sargent (1982), i n her study of the obstetric choice of women of the Bariba tribe of the W e s t African republic of Benin,

Charges w e r e fixed a f t e r an initial survey of prevaf.ling charges in surrouncling private/governmental health institutions, and following discussions with the town's health committee.

~1 (one naira) = $.25 approximately in 1987.

I - 4

developed a mode1 of health service utilization based oq the rationality of choice, The primary assumptions of the model were that people would select the most effective means to reach n coal or set of goals taking into consideration comparative cmts of alternative choices. The features of the model which i~ m u l t i - factor in nature include the social characteristics of the client such as educatio~. and occupation, her identification with the service provider, her concept of the condition for which help is sought, cultural expectations, past experiences, and existing alternatives. These are all features relevant to the present ~tndy.

Poole and Carlton (1986) haye reviewed the literature on health care utilization and suggested a model derived a.n a composite from the fremeworks of several others (Kohn and F'lilEte, 1976; Anderson and Fewman, 1973). Four sets of independ.snt variables, 'perceive2 need factorsg, predisposing fackors'; 'enabling factors', and 'health systems factorst influence the dependent variable 'utilizationw.The provision of a service can have an impact at two levels: the health systems factors which relate to the norms, policies, resources and organization within the service; and at the level of the enabling factors, whl.ch consist of affordability, availability, accessibility, and therefore acceptability of the service.

The provider of the service therefore has a limited influence. Predisposing factors which include the demographic and socio- economic characteristics, and knowledge and attitude of the potential users, as well as their perceived need for a servics are largely outside the provider's control. Yet these latter s a . h of factors are of great imoortance particularly in a rural commud.ty, A combination of these two approaches therefore seems vary appropriate. Furthermore, a study of the demographic and socioeconomic characteristics of the obstetric care clients will help to identify vulnerahle groups at whom future action m y r he directed. I

lth Servic e Ut il &tion Studies imeveXqlgina Co

Health services utilization in developing countriy now constitutes an area of research interest in many regions. Few studies however have been carried out in sub-Saharan Africa where

C maternal mortality has continued to pose a major problem. I n ,he East African region the pattern of utilization of health s e ~ 7 i c a s in rural Kenya has been analyzed in two separate studies (Van Ginneken and Muller 1984, Mwambu 1986). Freund and Kalumba (1385)

Studies have been carried out in the Philippines (Akin et al. 1985), Guatemala (Annis, 1981), Egypt (Abu-Zeid and D a m , 1 9 8 5 ) . and Jordan [Obemeyer, 1988; Abbas and Walker, l953), to name only a few outside sub-,Saharan Africa.

have monitored and evaluated primary health care services utilization in rural Zambia. In West Africa, Lasker (1981) in the Ivory Coast, Sargent (1982, 1985) in the Republic of Benin, and more recently Sauerborn and his colleagues (Sauerborn et al., 1989a, 1989b; Nougtara et al., 1989) in Burkina Faso have stueled health services utilization in the rural camnunitiea.

Okafor (1989), in her study of service utilization in rural Nigeria, stated that nJ-ittle is known about w h a t semicee exist in rural areas of Niqeria, the coverage they give, and the factors associated with service utilization'. Although there have been recent studies in Zaria, Enugu, Ilorin and Ihadan (Harrison, 1385; Chukwudebelu and Ozumba 1988; Adetoro, 1987; Otolorin et al., I9SR) such studies are ur;ually institution-based and often fail to reflect the.tnle picture at the community level.

OBJECTIVES OF THE STUJ'X

1.To determine the degree of utilization by pregnant women in Obukpa of prenatal, delivery, and post-natal services provided at the Comprehensive Health Center, and to identify the factors YF.~ influence the use, non-use or differential use of the variou.~ service components.

2.To assess the content of the maternal services.provided hy the Comprehensive Health Center.

3 .To identify other sources of maternal health. care to the community and detemhe $he extent of their use and the f a c t ~ m that influence this use.

I

.- ~ O D O m Y 4

Data was obtained from two sources: from the community, by a by household survey using an interview questionnaire; and from t5e health center by the analysis of existing routine health center records, and by personal interview of key staff. .

A fourth objectide was to compare the pregnancy .outcomas for users and non-users of the health center facilities. However, the small sample size employed in the study yielded very Pew adverse pregnancy outcomee and so made this aspect of the ctvdy impossible. .

4

Obukpa town consists of 59 villages divided into 4 quarters (Ejuona, Owerre, Obiqe and Oqbuagu) . Cluster sample units of 3 -- 8 villages were ran~~omly selected from each quarter depending on the sizes of the villages and the size of each quarter. A to ta2 05 22 villages were incl-uded in the sample.

Preliminary enumeration of the households in the selected. villages was undertaken and a census of the women in the househo?.dfi was carried out. All women who had a miscarriage, a live- or still- birth in the period from May 1987' to July 1989 were included in the study. A total of 488 women in 1062 households were intemriewed. All the women participated willingly.

High school graduates select'ed from each village were used as enumerators and were subsequently trained as interviewers for the administration of questionnaires. Professional staff of the Department of Commun.ity Medicine of the University of Nigeria, Enugu, served as trainers and supervisors of the interviewers. The survey lasted s i x weeks from early August to mid-September 1989.

The survey instrument was a questionnaire developed and validated by the. investiaator with inputs from other members of staff of his department. Data collected from the community relate to socio-economic and demagraphic characteristics of the women in the sample, to their sources of care in their last pregnancy. an6 delivery, and to accessibility and financial cost of servicefi received.

Health center data relate to facilities available, and content of services offered at the Comprehensive Health Center. Data were obtained from attendance and admissions registers, work schedules and duty rosters, ~ n d inventory of equipment and supplies. The doctor in charge or the center, and the midwives and community health officers responsible for maternal health care were interviewed to obtain their assessment of the constraints to n more effective service delivery.

lea I

The outcome variables'in the different sections of the study are registration for prehatal care, adequacy of prenatal care received, place of delivery and attendant at delivery, and. postnatal care.

Resistration for ~renhtal care is assumed if a woman made a v i s i t to a health institution during pregnancy for the purpose of .

7 -

obtaining care related to pregnancy, and is classified as 'yes' or 'no'.

Bdsauacv of ren natal care is classified as 'noneg, 'some' or 'adequate' based c m t ; . m e of registration for care- and the total number of visits ma6e during that pregnancy to a health institution. 'None' indicates that a 'woman did not regist~r for prenatal care, tadequate' that a woman registered within the first 4 months of pregnancy and made at least 4 prenatal visits to a health institution, and 'some' if she does not fall into either of the above two categories. It is recognized that this commonly uned quantitative measure 05 adequacy of care does not take into accannt the often more imortant factors 'of content and quality of care received during tke visits (Brown, 1988).

place of delivery is categorized as either at home or in an institution Qthe cbmprehensive health center or any other h5alth institution) . Adc'itionally, for analysis of a data set of only women who delivered in an institution (Section 111), place of delivery is re-classified into two categories: delivery at the comprehensive health center and delivery at other health institutions.

=tendant at delivemr is divided into two categories: delivery. by a trained p w f - s s i w a l (a trained nurse, midwife or doctor), and delivery by a traeitional birth attendant.

Epstnatal care is defined as receiving care in a health institution in the immediate postnatal period usually withi'n 6-8 weeks of delivery but often also beyond.

devendent variables

The followinq sets of independent variables were studied:

a. Hat-ernal factors - these include age .(in five-year intervals), education (none/primary/poat-primary), marital status (currently marrie6/currently not married) , parity (1-2/3-4/5-617 and over), and any previous 'wasted pregnancyt(stillbirth, abortion) .

b. Socio-economic factors - occupation of bxshand (farming/civil serv?.nt/others), and occupation of mether (Earming/petty trndin~/'no occupation').

ti Almost all deliveries at home were conducted by traditional birth attendants anC all institutional deliveries by trained professionals. The result of the study of the outcome variable attendant at delivery was therefore found to be very similar. to that of place of delivery, and is therefore omitted in this presentation.

c. w v s t r u ~ t u r ~ - monogamy/polygamy, residence of mother-. in-law.

d. ma - quarter (Ejuona, Owerre, Obige, and Ogbuagu) .

e. (traditional/Christianity)

For the evaluation of the Comprehensive Health Center, additional variables were analyzed:

f. m ancia1 cost care - charges paid by service gsers at the Comprehensive H e a l t P l Center and in other institutions . These include cost of registration for prenatal care, cost of d n g ~ per prenatal visit, and cost of delivery service.

g. Hode of t r a m - Information on mode of transportation to place of delivery was obtained for only those who sought lntrapartum care outside the home.

h. Distance of villase of residence from the Comareh-ensive H e a t h C -- enter - This was measured directly from a map producecl Yxom zn aerial photograph of Obukpa town. The villages are groupec?. in five categories dspending on their map distance fron t h e comprghensive health center ( < l k m ; 1-2km; 2-2.5km: 2.5-3km; 3107 and over) - .

i. X-.vea

Data from the survey were analyzed in two stages. First, the Statistical Analysis System, SAS (1985) was used to grovic?e descriptive statist.ics, cross tabulations and bi-variate cki- square test to indicate which independent variables have the strongest associatilm with the outcome variables under atuCy. Logistic regression analysis using EGRET (1985-1989) was then conducted to study the relationship between the outcome varhble and the independent variables shown to be associated with the outcome variable.

Multiple regression analysis is able to identify and estimate the influence of each of several variables on the outcome variz i le

Moslems and practitioners of other religions constitute only 1.8% of the study population and are excluded from the analyda. ,

Cost of service received at home usually from traditional birth attendants is not included in this analysis because the cost is often stated to be 'nothing' or payment in made in kind.

Distances to other health institutions were not availsble.

while controlling for others. The coefficients obtained for each independent variable where such a variable is binary is translated into an odds ratio which ia a direct measure of the magnitucle of the association hetw~en the factor and the outcome ~ i h i l e controlling for the effects of all other variables in the rodel (Klienbaum and Mor~enstern, 1982; ~ennekens and ~uring, 1987).

Orqanization ~f d a u analvsis

Data analysis and preeentatioh of results are organized into three sections: q

Section I outlines the content of the prenatal care offered at -the comprehensiw health center and analyzes the pattern of utilization of prenatal services as shown by data relatin? to registration for and adequacy of prenatal care.

Section I1 focuses on the utilization of facilities for i n t r a parturn care and for postnatal care. Delivery is analyzed in relation to place of delivery (home or institutional), The relationship between use of prenatal care and subsequent use of delivery and postnatal care services is analyzed.

Section I11 deals with the possible influence of distance and financial cost of services on the utilization pattern of maternal

. health services. It analyses the changing pattern of use of services since the inception of intrapartum care at the Comprehensive Health Center.

The outcome variable Adequacy of Prenatal carelo wae entered in the regression model as a dichotomous variable taking the value J. for adequate care, and 0 for no care or some, but inadequate' care. All independent vwriables were treated as binary and where a variable haC more than two categories this was achievecl by treating the base cat ego^ as a reference category to which ctber categories were then compared.

Table 1.1 describes the characteristics of the 488 women in the sample. The population is mainly agricultural with 44.9% and 34.4% of women and 44.93 of their husbands engaged in farming. 18.44 of the women stated that they had 'no occupation'. The level of education is low with under 10% of both males and females bsvj-ng had more than s i x years of schooling. Christians (61.1%) and practitioners of the tragitional religion (36.1%) make up the bulk of the population. 17% 05 the women are in polygamous marriages.

Table 1.2 shows that 93.4% of the women surveyed :lad registered for prenatal care. 61.7% registered at the Obukpa Comprehensive Health Center, 33.7% at other health institutions and only 2.6% with traditional birth attendants. However, only 5 . 7 % registered in Elrsttrfmester, with most of the registration taking place in the second trimester (80.9%) and only 13.4% in the l a ~ t trimester. Care recej-ved was judged adequate in 22% of the woEen using the criteria of initiftiion of care in the first 4 months and at least 4 prenatal visits.

Table 1.3 describes the effect of maternal and other factors on the delivery of adequate prenatal care. The younger, more educated, Christian mothers were more likely to have adequate care. The data suggest that increasing parity, being unmarried, farming as an occupation and a polygamous marriage are associated with a lower probability of receiving adequate prenatal care. A greater percentage of women with husbands in the civil service and with higher education had 'more adequate care'. The presence of a mother-in-law in the household had no influence on the adequacy 05

lo The outcome variable Registration for Prenatal Care was not further analyzed as the study population showed almost complete registration.

l1 This figure falle to 5.3% if the more stringent criteria of initiating care in the first trimester and at least 5 visits a r e applied.

care received.

When these variables were included in a logistic regression ~nalysis (Table 1.4), only maternal education was significamtly associated with adequacy of prenatal care (p < . 0 5 ) . Post prhary education increased the likelihood of having adequate prenatal care over three times and primary education 1.7 times compared to no' euucation. Residencn in Owerre almost doubled the likelihood although the figure just failed to reach the desired level of significance (p = . O R ) .

Appendix I outlines the sewices available at the Obulcpw Health Center. Appendix I1 gives an evaluation of the facilities. There are no facil.ities for blood transfusion and for the management of complicated. labor.

The outcome variable Place of Delivery was entered in the regression model as a dichotomous variable taking the value 1 for delivery in a health .i.nstitution, and 0 for home delivery. Similarly, the outcome variable postnatal care use was assign-d the value 1 for care r ived in a health institution, and @ for Y- no care or care at home . All independent variables were treatad an binary and where a variable had more than two categories, this was achieved by treating the base category as a reference category to which other categories were then applied.

The outcome variables Adequacy of Prenatal Care, Place of Delivery and Postnatal Care were cross-tabulated to detect anv association between them. Furthermore, Adequacy of Prenatal Care was added to the regression equation earlier obtained for t 3 ~ outcome variable pJ8ce of delivery to test its effect w b . 3 e controlling for the independent variables. similarly, Adequac:~ of Prenatal Care and Place af Delivery were simultaneously ind-udcd in the regression model for Postnatal Care to test their indivic'zah effects while controlling for each other and for the independent variables.

Of the 488 women in the study, 61.2% delivered in a health institution (Comprehensive Health Center 2 7 . 6 % , other institutions 23.6%), while 48 .8% delivered at home. Table 2.1 show^ thet

-- - - - - -

l2 Traditional birth attendants do not usually give any postnatal care at home in Obukpa, nor'do the health professionnls conduct domiciliary visits.

institutional delivery was high with married mothers of young Tige who have had some education, and among Christians. Women marrid- to husbands who had R o m e education and were employed in the c i v i l service were also more likely to deliver in a health institution. Farmers and the wives of farmers, multiparous women, and women inf polygamous marriages were more likely to deliver at home, Quarter ofresidence does not appear to influence choice of place of delivery .

Logistic regression analysis.(,Table 2.2) shows that education and occupation of the mother, religion, and occupation of the husband are significantly associated with delivery in a he33.th institution. Mothers with post-primary education are over 3 t i m e s more likely to deliver in a health institution than those with no schooling (p = .03); petty traders 1.7 times (p = .03), and w o w n with 'no occupationt 2.3 times more likely than farmers (p = .O?.) . Christianity increased the likelihood of delivery in a health institution 2.3 timen (p = .002) and marriage to a civil sarvmt 2.2 times (p = -006) . Quarter of residence and marital status ve-e not found to be signi'iicantly associated wit3 place of de1ivar)t.

78.8% of the women used postnatal care services in a health institution while 21.2% had no care at all or said that "hey received care at home, Obtaining postnatal care in a health institution (Table 2.4) was more likely in the younger, m r z educated, Christian women married to.civi1 servants or husSm-19 with some education (see Table 2.3). Increasing parity, farminu znd polygamy were linked to less use of institutional postnatal care facilities. obtaining postnatal appears to vary with quarter of residence.

Logistic regression analysis (Table 2.4) shows that religion, occupation of husbaod and quarter of residence were significantly associated with postnatal care when other factors were controll&.. Christians were 2.5 times more likely to obtain postnatal care (p < .001) as well as wives of civil servants (p = . 0 0 5 ) . Residence in Owerre and Ogbuagu quarters increase the chances of care 3 and 3.7 times respectively (p < . 0 0 1 , and p = -003) . Education and marital status show no significant association .with use of postnatal care services.

Table 2.5a and 2.5b show that receiving adequate prenatal care was associated with an increased proportion of women who deliverefi in health institutions and of women who obtained postnatal care. Similarly, delivery in a health institution was associated with an increase in the proportion of women who obtained postnatal care.

In the logistic regression analysis, Adequacy of Prenatal Care and Place of Delivery were significantly associated with obtainin? postnatal care when simultaneously added to the regression m ~ d d for Table 2.4. Those who had adequate prenatal care were twice more likely (p = .Ol9, OR ~2.08) , and those who delivered in a he~lth

in~titution were over 4 t i m e s more likely (p = <.001, OR = 4.79) to obtain postnatal care. The association between Adequacy of TJmnatal -.Care and Place of Delivery although pos i t ive , waa not fovnd to be eignif icant (p = - 0 8 8 , OR = . I. 56) .

Q

Cross-tabulations were done to determine ty3 pattern of utilization of the services by yedr of delivery . Place o? delivery was further analyzed by year of delivery applying selected independent variables known or expected to be associated with place of 8alivery (education of mother, occupation of mother, occupat!.cn of husband, religion, and quarter of residence). '

Analysis was carried out on a sub-sample of women who used health institutions for prenatal care and delivery and postnatal case. The aim was to determine the effect of distance from the compreheasive heath center on pattern of use.

Univarfate analysis was used to summarize andkcompare the cost of services at the Conprehensive Health Center and other health institutions and a frequency distribution was obtained for mode of travel to institutions for delivery.

The independent variable, Year of Delivery was added to the logistic regression models obtained in earlier analyses on "the outcome variables, Adequacy of Prenatal Care, Place of Delivery , and Posknatal Care use In order to quantify the change if any -1.n se.rvice utilization over time while controlling the independezlt variables,

Table 3.1 shows that a greater percentage of women used the cmprehensive health center for prenatal care in 1989 ( 6 s . 9%) v h e ~ c o ~ p r e d to 1987 (51.9?) with a corresponding decline in the use 02 ~ t h e r health institutions. However, no . improvement' has talrcn place in the time of initiation:of prenatal care. The proportion 13: women having adequate care has increased marginally but the um cT ~ostnatal care fac i l i t ies has somewhat decreased.

There was an increase in the proportion of women using the com?rehensive health center for delivery, from 1 4 . 8 % in 1987 to 25.92 in 1989, while other health institutions have maintained. a5ou': the same level of patronage. The net effect is a decrease in -':he overall percentage of the women who delivered at home, ax1

l3 The study covered the period May 1987 -- July 1989.

related decrease in the percentage of women who used the sawices of traditional birth attendants from 51.7% in 1987 to 30.2: in 1989.

Logistic regression coefficients and odds ratios for the use of institutions for delivery and the attendance of deliveries by trained professionals according to year show a significant change while controlling for other variables (Table 3.lb). Women were twice as likely to be delivered in health institutions in 1989 as in 1987 (p = .010, OR -- 2.216) and by trained staff (p = ,003, OR = 2.525). Changes in the adequacy of prenatal care and the use of postnatal care over the period were not significant.

. .

Table 3.2 analyzes the influence of some factors known to be associated with the use of institutions for intrapartum care on" changes in the use of delivery services between 1987 and 1.989. Although there hae been a general increase in the use of institutions and professional attendants for deliveries, the segments of the study population who previously used the services lepst in 1987 showed the greatest increases. Mothers with no education used the services of trained health professionals 1.7 times more, women who were farmers 1.6 times, and two-fold for non- christians and wives of artisans. Women who lived in Owexre and Obige ~ a r t f g s showed a 1.7 times and two-fold increases respctlvely .

Table 3.3 analyses the effect of distance from the Comprehensive Health Center on the use of prenatal care, delivery and postnatal care services. There is a reduction of percentaae of users of the services at the health center as the distance OF the place of residence increases.

The average fillancia1 cost of services at the Comprehensive Health Center was found to be slightly lower for delivery than in other institutions but about the same for registration and slightly higher for cost of drugs per visit (Table 3.4).

About one third of women who delivered away from hone travelled to health institutions on foot, another third travelled by bicycle or motorcycle, and only one third by car or bus (Table 3 . 5 )

- l4 Obige quarter is adjacent to the Comprehensive Health center which is located in Owerre quarter.

. . Pxena_tal Resistrat

Coverage of prenatal care in developing countries vari-es widely but is estimated generally to be low in most countries especially in the rural communities of sub-Saharan Africa. Figures by the World Health Organization show arrange of 33% for Madagascar ayd 90% for Gambia (FHO, 1985). For'a rural agricultural community with a low level of education, the level of registration for prenatal care (93.4%) obtained in this study is very good. Registration implies one or more visits to an institution during pregnancy and gives no indication' of the time of the visit or the overall number of visits. It tells nothing of 'the adequacyg of care received.

Adequacy of care is usually measured quantitatively by considering the time of initiation of care and the total number,of visits made before delivery. Different criteria. relating to tj.m.cs of first prenatal visit and total number of visits have been used in different studies. .The figures obtained from studies using different criteria present problems of comparison. In this stuey, adequate care was defined as care initiated within the first f c u r months of pregnancy ard a total of four visits. Lass than a quarter of the women in Obukna-were adjudged to have received 'adegiate care1. by these criteria. This figure comes falls to about 5'; -LC W.H.O. criteria are applied. The dominant factor in this e s t h e t e is the time of initiation of prenatal visits rather than L-lm averall number of visits. In Obukpa, care was initiated mostly !-n the middle trimester; the median time was the fifth month. Confirmation of a diagnosis of pregnancy is often not culturaliy acceptable in the edrly months of pregnancy, and prenatal care 5? therefore delayed.

If one accepts these criteria, then greater efforts must be made to improve the time of initiation of prenatal care as well ns the overall number of visits during pregnancy. The relevance of early registration for prenatal care and the overall number of visits during pregnanay has been questioned especially in the developing countries. The content of care rathex than the quantity may be more relevant in the face of problems of access. Hore research is needed to guide policy in this area.

Maternal education is the single most important factor influencing whether a mother receives adequate care or not . Harrison (1985), in Zaria, also showed that maternal education va6 '

the single most important factor associated with utilization of hospital facilities i.n pregnancy. The influence of education on health seeking behavior has been extepively reviewed (Grosse and Auffrey, 1989). Its role in stimulating maternal and child health

service utilization has been universally emphasized. However, the value of this finding for immediate action remains doubtful and better education for women can be seen in most communities in the developing countriee as a long term solution to the problem 05 maternal health.

Other independent variables studied are very closely rela'qd to maternal education. The mechanism through which maternal education produces its effect may be very complex. Occupation of mother, age of mother, occupation of husband, education of husband, and the family's religlon may be influenced by the level. of education of the mother and vice versa. The finding that they move Ln the same direction as education is therefore not surprising although they do no": necessarily reach a level of significance indivi6,ually when other factors are controlled for.

The presence of the mother-in-law in the household contrary to a popularly held belief does not influence whether a woman s e e k s care in a modern health care institution or in the traditional uector.

Women in Owerre quarter in which the Comprehensive Health Center was located were more likely to obtain adequate prenatcl care than those in other quarters. Since no village was over 5 kilopeters away from the health center, this implies that distances of this magnitude influence the use of facilities for prenctal care.

Traditional birth attendants rarely provide prenatal care in Obukpa. The role of these attendants in providing care in the various phases of pregnancy differs from community to community. Okafor (1989) in her study of another rural Nigerian communi2y found that 54.3% of t 11 pregnant women registered for prenatal car? with traditional birth attendants.

The traditional birth attendant is used in many parts 02 the world as a substitute for trained health professional. Whether this is out of choice or because no .alternative exists is often difficult to determine. Some studies have indicatedthat in some traditions, women would use traditional attendants even when adequate modern facilities exist side by side. However, given the population/midwife ratio in many developing countries, this c l w ~ of practitioners must often be the only alternative. In recognition of this fact, the training of traditional birth attendants has been embarked upon by various countries. The content of such training and. the role of the attendants in the structure of the health services axe often undetermined and have proved areas of conflict with the established health professions in many countries. The training of traditional birth attendants and their integration i n 3 aacountryBs health system has.its champions as well as its strong opponents (Harrison, 1.980; Editorial Lancet, 1983; Leedam, 1385). Circum~tances vary, and each country must formulate its own pol!-cy

based on its current qrealities.

Host of the woman in Obukpa obtained prenatal care from tm Comprehensive Health Center or from other health institutions mainly in the private sector. The role of t h e private sector in the provision of maternsl health care in the Obukpa community had. previously behn underestimated. One third of all pregnant woman registered for prenatal care with private . institutions. Private sector participation in health care delivery even in rural areas is a factor that needs to be .taken into consideration in formulating policy for mzternal care.

Services at Deliverv and Postnatal Care

In t h i s study nearly half (48.8%) of the women delivered at home. No domiciliary deliveries involved health personnel, and except for a small number of self deliveries, these deliveries were conducted by traditional birth attendants. This is in marked contrast to the near complete (93.4%) registration for prenatal- care in health institutions,

Four factors are shown to influence this choice, namely education and occupation of the mother, religion, and occupation of t h e husband. The pore educated a woman, the more likely she is to use the s erv i ce s of a trained health professional for delivery. Other studies have shown a-definite relationship between maternal education and improved pregnancy outcome for both mother and ch11d (Harrison, 1985). The mechanism for this. improvement probably involves the increased utilization of service by the more educated women where service utilization serves as a proximate determinant of the outcome. B

Mothers who were farmers were more likely to deliver at hone than in health institutions. This probably is a reflection of a number of different operating factors. Farmers.are less likely to be educated. Their income is seasonal and-they may not be able to afford delivery charges at the appropriate time. Traditional b k t h attendants take their remuneration in kind .&and monetary considerations pose no barrier to obtaining immediate care. Tor this latter reason, women married to civil servants may also have the economic power to pay for institutional delivery s i n c e civAL servants receive regular salaries. Women petty.traders also obtein fairly regular incomes from sale of goods. The 'no occupation1 group of women c o n s i s t s of a.younger group ofaeducated women w9o neit9er farm nor trade but are more likely to be married to relatively affluent men.

Although education and religion are correlated, the influence of religion and education on place of delivery remain individually significant when controlled for each other. Religion as a way of

life of the people must therefore influence their choice of a place of delivery. In the Bariba tribe of the ~epublic of eni in, the ability to deliver oneself without help is a greatly treasured performance (Sargent, 1985) . Other factors include the birth position and the rituals associated with delivery which cannot he carried out in a health care institution. Egwuatu (1986) has reported similar preferences among Ibo women of eastern Nigeria. Xdentif ication with the attendant plays a major role also in the womanVs choice of the traditional ,b ir th attendant. Factors which are operational vary in different cultures. An in depth qualitative' study needs to be done to determine the characteristics of 'religiong in the case of Obukpa which influences the choice of the traditional birth attendant over the modern health professional.

No significant difference was found in patronage of health institutions for delivery according to the quarter of residence of the mother. Mothers who lived in other quarters were no less likely to use a health center than those in Owerre quarter where the Com?rehensive Health Center is located. This implies that the nearness of the Health Center did not influence the choice to deliver at home or !-n a health center.

Most women received postnatal care in a health institution. Husband's occupation, religion, and place of residence were significantly associated with receiving care in a health institution. Thus distance from the health institution ~~~ . i , 3 -k influence the decision to seek postnatal care as will the ability of the husband to pay for the care. Civil servants form a group who receive regular incoae. Religion, but not education, was associ?.ted with use of postnatal care. This surprising finding requires further investigatirn.

1

A relationship exists between the use of one service and the subsequent use of other services. This study shows a greCer likrlihood of the use of institutions for postnatal care by wonen who had adequate prenatal care and women who delivered in health care institutions. Adequacy of prenatal care also increased. the likelihood of delivery in a health facility. A relationship has also been shown between the use of maternal care facilities for pregnancy care and delivery and family planning, as well as the use of child welfare clinics. Furthermore, previous contact with a health care facility prior to pregnancy has been shown to increase the likelihood of women using health facilities d:nr%ng pregnancy (Okafor, 1989). Use of health facilities is there-re a #learned habit1 which is self-perpetuating. It has however bean argued that pregnant women choose their preferred place of delivery first, and are then more likely to register for prenatal sand postnatal care in the facility of their choice. Both mechanisms probably operate. .

In establishinq a health center at Obukpa it was hoped that the problem of physical accessibility w ~ u l d be solved. No village in the town is more than 5 kilometers. away from the Center.' Attempts were made to fix charges at a level that it was believed the community could afford. ~ualified staff were employed. to guarantee quality care. These factors were all calculated to ensure optimal patronage. .

The study indicates that there was atwo-fold increase in the use of the center for delivery between May-December 1987 and January-July 1989. The proportion of women using the service^ of traditional birth attendants fell from about a half to below a third. Alghough a large percentage of the women still used the cheaper traditional birth attendants, bringing a facility close to the community has eroded the domain of the traditional b k t h attendants and severely diminished their share of the market whj.7.e patronage of other health facilities have remained unchanged..

Decisions regarfling the place for delivery seem to be taken at two distinct levels, firstly whether to deliver at home or .:.n a health institution, and then which health institution to use Lf institutional delivery was decided on. It was shown earlier that the quarter of residence did not influence the first. level of decision. The women living-nearer the Health Center were as likely to deliver at home as the women in other quarters. However, when a decision has been taken not to deliver at home but to use a health facility, distance became an important consideration. TIlen, the farther away a woman lived from the Comprehensive Health.Cen",er the less likely she was to use the center. This applied not on:-y to delivery but to prenatal and postnatal .care.

b

The mode of transportation in Obukpa helps to explain the importance of distance as a determinant of the choice of institution for delivery. Only about a third of the women in labor who delivered away from home had the use of a car or bus for transportation to the place of delivery. The rest had to travel on foot, by bicycle or motorcycle. Given these circumstancarl: the nearer facility becomes the obvious choice.

. The greatest increases in the proportion of users was among

the groups whose use of the institution had been poor in 1937 - the uneducated, the farmers, and the non-Christians. Proximity can therefore override other factors in determining choice of institution. From the point of. view of equity, the health center seems to serve a real need for the underprivileged. Government policy to place as many health centers as near the people as possible can then be seen as a realistic approach. Finanaial and other constraints, however, place a limit ,on the number of such facilities that the state can provide and the question of location of the available facilities paradoxically poses serious equi ty

problems.

Three points ctand out concerning the cost of services. Firstly, despite ef "rts a t fixing af f.ordable charges, the study showed that charges at t h e Comprehensive Health Center were no lower than in other health institutions which were mainly in the private sector. The patronage of the Comprehensive Health Center vas therefore not rblated to lower charges. Secondly, most of the new clients of the Comprehensive Health Center came from the sector of the community which had hithe~to uaed the traditional bir th attendant at a much lower cost. They were prepared to pay if they considered the service worth the cost. Thirdly, quoted official charges at government institutions may reflect only part a' the costs borne by service users. Many of the clients actually spent more than the estimated official charges in the Comprebeenive Health Center.

The findings of this study point to a number of conclusions which should form the basis for future action to improve service. Certain fundamental questions are also raised which call for more research especially in the area of policy.

Registration for prenatal care was found satisfactory but quantitatively care was largely ninadequatem. The criteria us& for t h e determination of adequacy of care which were copied from developing countriee need to be re-appraised. Most women prefer td register for care at the fifth month of pregnancy. What is the optimum time for initiating care and the desirable number of visits? I

Education and socioeconomic status are two factors found to be correlated to service utilization. This underscores the met! for a general improvement in the lot of the people and particularly a greater investment in women's education. These are long term measures and must not be seen as an alternative to providing needed facilities. More refiearch is needed on the meaning of 'traditional relLgionW which so strongly influences the choice of traditional care.

Traditional birth attendants are used by a large proportion of the women for deliveries, not because of the inaccessibility of modern care facilities but out of choice. The study failed to fully investigate other possible factors influencing the choices of delivery case. Qualitative methods of inquiry like the use of focus group technique should be employed. An extension of the study is also necessary to compare pregnancy. outcomes in clients of the traditional birth attendants and those of the health professionals.

Proximity of a health institution the domain of the traditional birth process which is also dependent on how

was shown to gradually erode attendant. This is a slow much can be allocated to .new

t"acilities and to healthmanpower. In the present economic ~ l i r n a t s , ~ the picture is bleak. Yet, government policy on the statuq of traditional birth attendants has remained vague. Although the role of traditional birth attendants may vary from area to area, this role ought to be fully defined based on objective research devoid af the sentiments that currently cl,oud the issue.

The private sector plays an important role in the delivery of maternal health care ser~lcea in the rural community. Thie role is being increasingly recognized by the government in Nigeria, Fowever, because of the government's promise to provide it^ o m care for the pebple, duplication of facilities is common. If as this study suggests charges for services are similar, and there is no preference by the cornunity for a public sector facility in maternal health care, then a re-definition of the relationship between the public and private sector is needed. Should the government assign areas of care to the private sector, and j-E SO, what areas? What guarantees exist against cost escalation if the present moderating effect of the public sector is withdrawn?

The role of the tertiary institutions in the delivery of primary health care should also be re-examined. The Comprehensive Health Center at Obukpa ought to serve as a referral center for the surrounding institut-.on& and be adequately equipped to play t h a t role. Its performance in intraparturn care should then be judged by the number of complicated cases treated.

Many etudies of sewice usage in developing countries p o i n t to identical determjnants of utilization. W.at is now p e e d 4 is ection based on the findings of the studies.

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Abu-Zeid, H. and W. Dam. Wealth Service utilization and cost in Egypt, nu S o c i a S c i e m ! g 21 4 (1985) : 451-61.

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TABLE 1.1 VARIABLE DESCRIPTION AND SAMPLE CHARACTERISTICS OBUKPA SVRVEY ON USE OF HATERNA?J HEALTH SERVICES

Variable name Categories Number (%)

Mother's age i n years

Education of mother

15-19 23 ( 4 .9 ) 20-29 256 (54.1) 30-39 165 (34.9) 40-49 29 ( 6.1) missing data 15

none primary only post primary

Marital Status currently married currently not married missing data

Parity 1-2 3-4 5-6 7 and over missing data

Any previous Yea 'wasted pregnancy' no (stillbirth,abortlon)

missing data

-Occupation of mother

Religion

fanning petty-trading others 'no occupationg

traditional christianity moslem,others missing data

Marriage structure monogamy polygamy missing data

Resident mother-in-law

yes no missing data

28

Table 1.1 (contd)

Variable name Categories Number (%) -

Age of husband 15-29 in years 30-39

40 -49 - 1 50-59 8

60 and over missing data

Education of none husband primary only

post primary missing data

Occupation of husband

Residence by quarter .

farming civil servant artisans etc missing data

Ej uona Owerre Obige Ogbuagu

Distance of village less than lkm 56 (11.5) from Compreh~nsive 1-2km . 8 1 (16.6) Health Center 2-2.5km 156 ( 3 4 . 0 )

2.5-3km 102 (20.9) , 3km and over 83 (17.0)

Year of delivery 1987 (May-Dec) 141 (28.9) 1988 217 (44.5) 1989 (Jan-July) 130 (26 .6 )

TABLE 1.2: UTILIZATION AND ADEQUACY OF PRENATAL CARE BY OBUKPA WOMEN

Prenatal care

Any prenatal care N u m b s . E - a Yes 456 93.4 No 32 6 . 5

Total 4 8 8

Registration by trimester

F i r s t 2 6 5.7 Second 369 8 0 . 9 "Third. 61 13.4

Total 4 5 6

Number of prenatal v i s i t s

~ e s s than 5 127 27.53 5 or more 329 7 2 . 2 Total 456

Adequacy of Prenatal care

None 32 6 . 5 Some 3 4 8 71.3 Adegu,ate* 108 22.1

Total 488

* Adequate prenatal care = initiation of care within the first 8. months of pregnancy plus 4 or more prenatal v i s i t s .

TABLE 1.3 OBUKPA SURVEY ON USE OF MATERNAL HEALTH SERVICES PERCENTAGE OF WOMEN WITH ADEQUATE R-WNATAL CARE

Variable

3 of women w i t h

Categoriee Adequate care - - - - -

Mother's age in years

Education of mother

none primary onll- post primary

Marital Status currently married currently not married

Parity 1-2 3-4 5-6 . over 6

1

Any previous Yes "wasted pregnancytt no stillbirth,abortion

Occupation

Religion

farming petty-trading 'no occupation3

traditional christianity

Marriage structure monogamy polygamy

Residence of mother-in-law

yes . no

Table 1 . 3 (contd)

Variable

% of women I with

Categories Adequate C a r e

Age of husband 15-29 . , 5 0 . 0 in years 30-39 27.4

40-49 23.7 50-59 17.5 60 and. above 00 .0

ducati ion of husband

occupation of husband

Residence by quarter

none primary only post primary

farming civil servant art isans etc

E j uona O w e r r e Obige Ogbuagu

TABLE 1 . 4 : LOGISTIC REGRESSION ANALYSIS OF THE-ADEQUACY QF PRENATAL ChPPi;: R Y OBUKPA WOMEN AGAIFST EATERNAL VARTABLES

I 95% Co- Standard Odds Confidence

Variable* efficient Error, Ratio Interval- P-velue

Intercept

Education of mother

Primary only Post primary ( N o n e )

Earital status Currently not married (Currently

. married)

Feligion Christianity (Traditional).

Occupation of husband

civil servant Artisan (Farming)

Quarter of Fesidence

Owerre Obige Ogbuagu (Ejuona)

Likely Ratio Statistic on 10DF.= 150.859, p < .001

TABLE 2.1: OBUKPA SURW3Y ON USE OF MATERNAL HEALTH SERVICES PERCENTAGE OF WOMEN DELIVERED IN J5EALTH CEYTRRS

Variable

9 Deliveries in a Health

Categories Institution

Mother's age 15-19 in years . 20-29

30-39 40-49 .

Education of mother

none primary only post primary

Marital Status currently married currently not married

Parity 1-2 3-4 5-6 over 6

Any previous ' Yes 'wasted pregnancy1 no

(stillbirth,abortion)

occupation

Religion

farming petty-trading 'no occupation'

traditional christianity

Marriage structure monogamy polygamy

Residence of mother-in-law

Table 2.1 (contd)

-

% Deliveries in a Health

Variable Categories Institution -

Age of husband 15-29 62.5 in years 30-39 - 6 0 . 8

40-49 s 51 .5 50-59 39.7 60 and above 26.7

Education of husband

Occupation of husband

none . 37.8 primary only 58.4 post primary 79.5

farming 36.6 civil servant 73.1 artisans etc 60.0

Residence by Ej uona quarter Owerre

Obige Ogbuagu

TABLE 2.2: IXGISTICI R E G M S S I O N ANALYSIS OF DELIVERY IN A HEALnfT INSTITt7TT@~ BY MATERNAL WARIARL?S

- -

95% Co- Standard Odds Confidence

Variable* e f f i c i e n t Error . R a t . i o Interval B-va lue

Intercept -1.444

Ed.ucation of mother

Primaryonly .2853 Post primary 1.202 (None)

Marital status Currently not married a.2142 (currently . - married)

Occupation of rother

Betty trading - 5 4 3 8 'No occupationv ,8512 (Farming)

Religion ~hristianity . t . 4 3 1 (~raditional)

occupation of husband

Civil servant .8177 Artisan - 2 3 5 3 (~arming)

Quarter of Residence

O w e r r e -.I457 .381 Obige -.0074 .321 "gbuagu .I745 -361 (E juona)

Likelihood Ratio Statistic on 12 DF = 69.850, p < i 0 0 1

*. The reference category is in parenthesis. All categories axe dichotomous

TlBLE 2.3 OBUKPA SURVEY ON USE OF MATERNAL MEALTH SERVICES PERCENTAGY OF POPIEN WITH POSTYATAT, CAFCE IM A HEALTX INSTITUTION

Variable

% of w o m e n with P o s t -

Categories natal Care

Mother's age in years

Education of none mother primary only

post primary

Marital Status currently married currently not married

Parity 1-2 3-4 5-6 over 6

Any previous . yes 'wasted p r e g n a n ~ y ' no (stillbirth,abortion)

occupation of farming mother petty-trading

'no occupation'

Religion traditional 55.9 christianity 79.5

Marriage structure monogamy polygamy

Residence of Y e s 69.7 mother-in-law no 76.4

Table 2 .3 (contd)

Variable

9s of women with Post-

Categories n a t a l Care

Age of husband 15-29 ' in years 30-39

40-49 50-59 60 and'above

Education of husband

Occupation of husband

none primary only post primary

farming c i v i l servant art isans etc

Residence by Ej uona quarter Owerre

Obige Ogbuagu

TABLE 2 .4 IDGISTIC REGRESSION ANALYSIS OF POSTNATAL CARE IN A HEALTFI: IFISTITUTIOM BY MATERWAL VARIABLES

95% Co- Standard Odds Confidence

Variable* efficient Erro-r Ratio Interval P-value

Intercept -, 6016

Education of mother

Primary only - - . 0 2 4 8 .285 -9755 .5578-1.706 931. Post primary . 4 6 2 3 . 5 3 5 ' 1.588 -5369-4.526 . 3 87 (none)

Marital status Currently not married -.2161 .619 .8057 .2396-2.709 ,727 (currently married)

Religion Christianity ' .9451 .287 2.573 1.466-4.516 <.001 (Traditional)

Occupation of husband

Civil servant . 9 2 6 5 -332 2.526 1.316-4.846 .005 Artisan -. 0092 .280 1.009 .5834-1.746 .974 (Farming)

Quarter of residence b

Owerre 1 .311 .385 3.710 1.745-7.888 <.001 Obige .2316 .312 1.312 .7112-2.420 .305 Ogbuagu 1.114 -378 3.048 1.453-6.391 .093 (Ejuona)

Likelihood Ratio Statistic on lODF = 116.332, p < .001

* The reference category is in parenthesis. All categories axe dichotomous

TABLE 2 . 5 : OBUKPA SURVEY ON USE OF MATERNAL HEALTH SERVICES INFLWENCS OF SERVICE UTILLZATXOM OM SUBSEQUJTT USX OF OTPW SERVICES

Place of Delivery

Home delivery Camp. Health O t h e r Health Center Institutions

Number % Number 4 N m 5 e r %

Adequacy of Prenatal care

None 2 5 96.2 0 00.0 I. 3.8

Some 166 49.5 89 2 6 . 6 8 0 23.3

Adequate 37 34 .9 4 0 3 7 . 7 29 2 7 . 4

Ib) Postnatal care bv adecrugsrv of nrenatal care

No Postnatal care Postnatal care Nuraher % Number %

Adequacy of prenatal care

None 13 59.1 9 40.1 I

Some 7 0 21.1 262 7 9 . 9

Adequate 14 13.5 90 8 6 . 5

(c1 Postnatal care bv place o f deliverv

No Postnatal Care Postnatal Care 1

Number % Number % - -- - --

Place of delivery Home 68 31.92 145 68.1.

Comp. health 15 12.0 110 88.0 Center

Other health 11 10.4 95 89.6 . Institutions

TABLE 3.la: OSUKPA SURVEY ON USE OF MATERWAL HEALTH SERVICRX PERCENTAGE UTILIZATION OF SE9WCE.S RY YEAR (MAY 1987-JULY 11989)

Outcome variable

Any prenatal care (p 1 (*) ( % ) (a) Yes 92.2 92.2 96.9 93.4.

NO 7 . 8 7 . 8 3 . 1 6.5

Place of prenatal care Comprehensive Health Center 51.9 6 5 . 5 65.9 61.7

O t h e r health institutions 41.2 30.5 30.9 13.? T r a d i t i o n a l birth attendant 4 . 6 2.0 1.6 2.G

Others 2.3 2.0 1.6 2.0

Registration by trimester First 6.2 6 4.7 5.7 Second 7 4 . 6 8 2 . 4 85 80.9 Third 19.2 1.6 10.2 '73.6

Adequacy of prenatal care None 7 . 8 7 . 8 3 . 1 6 . 6 Some 7 3 . 8 7 0 . 5 7 0 . 8 7 1 . 3 ,.

Adequate 18.4 22. X 26.2 22.1

Delivery place A t home 60 4 7 . 9 38.2

Comprehensive Health C e n t e r 1 4 . 8 3 1 . 1 35 .8 Other health institutions 25.2 21.1 26

Attendant at delivery Trained professional 40.7 52.9 62

Traditional birth attendant 51.4 - 4 0 30.2 Others(self,neighhoxs etc) 7.9 7.1. 7.8

Any postnatal care Yes 80.9 7 8 . 5 77.1 78.8 No 19.1 21.5 2 2 . 9 21.2 .

TARLZ 3.1B: LOGISTIC REGRESSION COEFFICIENTS FOR THE YEAR. OF DELIVERY @*I SERVICE UTILIZATIO'J VA,9XABT_LT=S

Service Utilization Variables

Adequacy of Place o f Attendant Postnatal Year of Delivery Prenatal care Delivery at D ? l i v e r y cXr2

1987 (reference category)

-. 1207 .2602 -2136 --. 436

.3231 .7955 (a) - 9 2 6 2 (b) - . A 2 6 9

( 7 ) p - .010, OR = 2.216 (b) p - -003, OR = 2.525

TABLE 3.2: OBUKPA SURVEY ON USE OF MATERNAL HEALTH SERVICES CHANGES IN PERCENTAGE OF DELIVERIES BY TRAINED PROFESSIONAL ATTENDANTS BY Y E W . O F DELIVERY

Variable Categories 1987 1989 Chance (%) ( % I

- - - -- -

Education of , none 27.0 45.5 1.7 mother primary only 53 - 3 68.4 1 . ?(

post primary 8 3 . 3 94.1 .1

Occupation

Religion

farming 28.3 46.0 1.6 petty-trading 4 3 - 8 69.0 1.5 'no occupation'52.9 62.3- . 2

tradit ional 20 .0 chrintianity 5 8 . 4

Occupation of ' farming 33.9 husband civil servant 71.0

artisans etc 35.3

Quarter of E j uona 5 3 . 6 residence O w e r r e 36-0

Obige 31.4 Ogbuagu . 47.2

TABLE 3.3: OBUKPA SURVEY OF THE USE OF MATERNAL HEALTH SERVICES USE OF T9E COMPREHENSIVE HEALTH CENTER FOR DELIVET:! ACCORDING TO DISTANCE OF RESIPTNCE FROM THE COYPREHENSXVE EEALTM CENTER

% of women using CHC service* --

Prenatal Delivery Postnatal Variable Categories Care Care

Distance of <lkm 92.5 87.0 86.4 village from comprehensive 1-2km 63.9 59.2 61.9 health center

2-2.5b 67 .4 6 0 . 5 71.6

3km & over 47.5 23.5 46.7

* Only women who delivered in a health institution wern included in the analysis.

TABLE 3.4: OBUKPA SURVEY ON USE OF MATEFUJAL HEALTH SERVICES COST OF PRENATAL CARE AND .DELIVERY

Cost of senrice i n Naira - - - p p p

Comp. Health Other health . Center institution5

prenatal care Registration

Cost of drugs per v i s i t

mean medj-an/mode

mean median/mode

mean median/mode

TABLE 3.5: OBUKPA SURVEY OM THE USE OF XATERNAL HEALTH SERVICES MODE OF T W E L FOR WOMEN WITH X?TSTITUTIONAL D!3LjltTX'S' AT THE COKPREHENSIVE HEALTH CENTZR OR M Y OTPX? INSTIT'JTIOV

Mode of travel Percentage

Ambulance 0 . 4

On foot

By bicycle or motorcycle 36.2

Private car, 29.3 taxi or bus

APPENDIX I - OBUKPA COHPIWHENSIVE HEALTH CENTER - SERVICES 01?F59?9 The Weal clin

following services are offered at the Obukpa Comprehsn?itre 1 V R th Center. All Clinic are held once weekly except curat'

ic held daily. There is 24-hour emergency cover.

Group health education covering range of topic^ urine testing for sugdr and protein. blood test for Hemoglobin checking and recording of blood pressure weighing abdominal palpation for fetal position and l i s t m i r ~ to fetal heart

referral to a hospital when necessary.

Schedule of v i s i t e

Registration - 'from about 12 weeks gestation or eve-n earliert

v i s i t s - 4 weekly intervals till 28 weeks gestation, 2-3 weekly intervals till 36 weeks, t h e n weekly until birth. Extra visits are fixed-if necessary

ii. postnatal caLe_

6-8 weeks after delivery

Methods offered include rhythm, use of condoms, caps with barrier creams, oral contraceptives and 3CCD.

2 . Child Health services

This includes: Group health education Growth monitoring (monthly weighing of the children) Immunization (EPI Program) Individual discussions with mothers

3 . curative Care

Treatment of common adult and pediatric ailments and appropriate referrals.

APPENDIX I1 OBUKPA COMPREHENSIVE HEALTH CENTER ASSESSMENT OF FACILITIES

Staff 1 physician 15 trained nursin~/midwifery staff 5 nursing a u x i l i a r i e s .

Zquipment - adequate for prenatal and postnatal c l i n i c adequate for normal delivery, but no facilities for surgical intervention

Pharmacy - good supply of drugs, occasional shortaqes due t.0 supply procurement and supply system.

- intravenous fluid available and venesection sets. - adequate storage facilities and r e f r i g e r a t i o n for vaccines

1-aboratory- none, Haerrnoglobin estimation and urinalysis done .-ari.t.'?

test strip papers - no blood banking facility. Blood usually o b t a i x d by patient when needed from t h e misqion hospital i :~ t?? town abouz 8 kilometers away.

1

'hysical f a c i l i t i e s - adequate c l i n i c , office and ward space - staff a c c o ~ a o d a t i o n on site - good access road, but center loc~ted away f r o m t o m center

- electricity from nat ional grid plus a stand-by pS3nt - no pipe9 water supply, water provided by a t a n k e r

fairly reaularly - telephone Link from 1989

Transport - one ambulance and a minibus adequate fuel supply