Factors Associated With Use Of Maternity Services In Enugu

1.1 INTRODUCTION

Maternity mortality in developing countries has been described as a “multitude of quiet tragedies” and a “disgrace to the modern world”1. This is particularly true in sub – Saharan African where large numbers of maternal deaths occur each year because of high maternal mortality ratios and high fertility ratios2.

According to current World Health Organization (WHO) estimates, although 25 percent of women of reproductive age live in the developed countries only one percent of maternal deaths take place in these countries3. On the other hand, whereas 11 percent of women of reproductive age live in Africa, 30 percent of maternal deaths occur there3. This is 173 percent more  than would be expected based on population alone3. Indeed, as maternal mortality rates in developing countries are frequently under estimated by 50% the true incidence of maternal mortality might be closer to 1 million per year3.

This marked difference in reproductive outcome between developed and developing countries did not occur by chance. Access to quality care during pregnancy and especially at delivery seems to be the crucial factor in explaining the disparity in maternal mortality rates between the developing and the

be avoided if adequate care were provided5. Access is believed to increase utilization, and increased utilization to improve pregnancy outcome. Other factors contributing to this problem include inadequacy of the health care facilities, lack of information, negative cultural practices, unavailability of supplies and equipment in health institutions, poor quality of care and delay in obtaining emergency health care due to lack of transport among other reasons4. People in developed countries have recognized that although pregnancy is a natural phenomenon, things could go wrong and therefore have ensured that every woman has prenatal care and supervised delivery5.

In many communities in Nigeria, pregnancy is the most hazardous enterprise that a woman can undertake. Maternal deaths occur either at home without trained birth attendants or en route to hospital6.

While poverty and deprivation contributed considerably to maternal death, inadequate availability of preventive services,  such as prenatal, intra partum and post partum care also play major roles. The depressed economy in Nigeria today has marginalized the benefits of education with the result that educated women are not making use of existing health facilities because they cannot afford the financial burden6. Many therefore do not

have prenatal and intrapartum care or resort to such care in the churches or other under-staffed and ill-equipped medical centres and many lives are lost 6,7,8.

Therefore, maternity services have a potentially critical role to play in the improvement of reproductive health in sub-Saharan Africa9. There is evidence that routine care for all pregnancies and access to skilled assistance and well equipped health institution during delivery can reduce maternal mortality and reproductive morbidity and improve pregnancy outcome10,11, 12. For instance analysis of Demographic and Health survey data from Finland demonstrate that higher levels of health use in pregnancy and delivery are associated with better outcome 13. Only about one- third of all births are assisted by trained attendants in Africa and South Asia, and 64% in Latin America as opposed to 93% in East Asia and virtually 100% in North America 14.

It is important to plan the place of delivery and maximize the chances that a skilled attendant will be present in order to reduce both maternal and neonatal deaths which occur largely as a consequence of inappropriate care during delivery or the first critical hours after birth14. Inspite of these, there is a tendency  even amongst booked patients to bow to tradition and try  delivering at home15. In a rural area of Northern Nigeria, 92% of the women had their deliveries at home while only 7.9% of the births occurred either at the district rural health centre or hospital inspite of the fact that about twenty four percent of the mothers  had initially attended the health centre for ante-natal care7. In another study in Ibadan Nigeria,16 despite the fact that 87% of the women made use of antenatal care services, nearly half of the children were born either at home (40.2%) or in the farm (9.7%). Among women delivering at home, 45% were assisted by mothers- in-law, 38.7% by neigbours and 22% had no help at all. The reasons the women gave delivering at home include lack of transportation, being unaware that labour was advanced until it was too late and the influence of their mothers and mothers – in law who had delivered their own babies at home. Home deliveries in low income countries contribute immensely to maternal mortality as they are bound to be unhygienic and unsupervised17. Additionally, decision making is often rested solely on the husband with disastrous consequences. It means that when labour becomes difficult at home, in the absence of the husband, transfer to hospital gets delayed so that obstruction is nearly always advanced  when  it  is  eventually  relieved  by  operation18. The failure to report early for professional care when things go wrong is very much a characteristic of obstetric care in Nigeria19. Logistics apart, there are cultural, traditional and religious factors as well as the fact that sometimes people are too poor to afford transportation costs and hospital fees. Then there are defects in the organization of health services in Nigeria not to mention all sorts of misdemeanours among the health care workers themselves19.  The organization of health services in Nigeria is such that there is no proper referral system between the primary, secondary and tertiary levels of care20. Maternal health care needs to be a linked system operating at different levels and at different points in the reproductive cycle14.

The maternity care situation in Nigeria is such that tertiary care centres take on low risk obstetric cases while primary health centres take on high risk cases which should appropriately be handled by tertiary centres. In other words, in the absence of a proper referral system, parturients who utilize obstetric services deliver in facilities where they should not vis-à-vis their risk status.

Earlier studies explored the utilization or non utilization of obstetric services in rural areas 7,16,21,22 or tertiary care centres 23,24,25,26 . But amongst women who utilize obstetric services in Nigeria, little is known about the factors determining their  choice  of place of delivery.