Nonchalant attitude of pregnant women toward antenatal care because of the services of traditional birth attendants and its implications

Introduction

Antenatal care refers to the care that is given to an expectant mother from the time of conception till labour begins (Myles, 2003). The rapid development in the health system and the growing use of technology makes it impossible for any health system in any country to reject the use of western health care in all aspect of health delivery such as maternal care. In today’s world, every pregnant woman is encouraged to have some technological intervention during pregnancy.

Antenatal care is aspect of technology which is broadly accepted as way to improve women’s health even though some studies have disputed the advantages of some of the components of antenatal care. Care during pregnancy, child birth and post natal period is often provided by multiple care givers, many of whom work only in the antenatal unit. Effective antenatal care is expected to improve the health of women and infants, though some safe motherhood advocates questions on the effectiveness of antenatal care in the control of maternal mortality (McDonagh, 1996).

There is little doubt that maternal health education and instructions about the recognition of symptoms leading to obstetric emergencies, usually given at antenatal sessions, can be life saving and reduce delay in seeding help (Bhatia, 1995). In highly fertile societies such as developing countries, the antenatal period offers an opportunity to address other health related issues in women of reproductive age (Arrolietal, 2001). Counseling and voluntary screening for HIV, prevention of maternal to child transmission of HIV and the introduction of parturient of the use of insecticide treated bed nets have been successfully integrated into antenatal care. Furthermore antenatal care provides an opportunity to obstetricians and midwives for prevention and early detection of maternal conditions such as anaemia, malaria, hypertension and other medical conditions attending maternal health.

Antenatal care (ANC) services indirectly saves the lives of mothers and babies by promoting and establishing good health before child birth and the early post natal period. It often presents the first contact opportunities for pregnant women to connect with health services, thus offering an entry point for integrated care, promoting healthy home practices, influencing care-seeking behaviours and linking women with pregnancy complications to a referral system, thus impacting positively on maternal and foetal health. The very low maternal infants morbidity and mortality rates reported for developed countries compared with the extremely high figures in developing countries have been attributed to the high utilization of modem obstetric services by the former currently of women world wide utilizes antenatal care (ANC) services and in industrialized countries south Asia and sub – Saharan Africa.

Conceptual framework

Antenatal care is largely established and gives an opportunity to inform and educate pregnant women about pregnancy, child birth, care of the new born. Cowan (1995) noted that the aim of antenatal care is to enable expectant mothers make appropriate decisions about health will lead to optimum outcome of pregnancy and the newborn care.

According to Ejebe (2007), poor quality health care in Africa and Asia account for 95% of neonatal death. The developing world sum up the 99% of maternal death and half of this mortality occur in sub — Saharan Africa. A child born in some of these developed countries are more likely to die in neonatal period than children born in industrialized world (Allender, 2001).

A traditional birth attendant (TBA), also known as a traditional midwife, community midwife or lay midwife, is a pregnancy and childbirth care provider. Traditional birth attendants provide the majority of primary maternity care in many developing countries, and may function within specific communities in developed countries.

Traditional midwives provide basic health care, support and advice during and after pregnancy and childbirth, based primarily on experience and knowledge acquired informally through the traditions and practices of the communities where they originated. They usually work in rural, remote and other medically underserved areas. TBAs may not receive formal education and training in health care provision, and there are no specific professional requisites such as certification or licensure. A traditional birth attendant may have been formally educated and has chosen to not register. They often learn their trade through apprenticeship or are self-taught; in many communities one of the criteria for being accepted as a TBA by clients is experience as a mother. Many traditional midwives are also herbalists, or other traditional healers. They may or may not be integrated in the formal health care system. They sometimes serve as a bridge between the community and the formal health system, and may accompany women to health facilities for delivery.

The Ministry of Health in 2002 States that Nigeria has the second highest maternal mortality rate in the world. 8 out of 1,000 women died due to maternal health complications. This is due to factors that include the lack of skilled birth attendants (only 35% of Nigeria women have a skilled attendant at delivery). Davis (2005) reported from his study that financial difficulties are one of the most important reasons for not seeking health care for those within low income. In China, calls for the adoption of the antenatal care model termed focused antenatal care (FANC) have emanated from the desire to correct the poor implementation of traditional antenatal care (ANC) in developing countries. The FANC model is intended to reduce waiting time during antenatal visits and increase the time spent in educating women on pregnancy related issues (WHO, 2001).

The traditional ANC involves a pre-clinical session in which nurses socialize with patient through songs and prayers followed by a health talk and an interactive session of question and answer. Clinical consultations then follow in open spaces, partitioned clinic spaces or consulting rooms depending on the facility available in the centre (Corea, 1985).

Antenatal clinic appointments are given monthly until 28 weeks, fortnightly until 36 weeks and then weekly until delivery, counselling and screening for human immunodeficiency virus (HIV), syphilis and hepatitis are integrated into traditional ANC. Treatment of HIV and the prevention of maternal to child transmission of HIV are provided in specialized clinics (William, 2001).

Effective antenatal care is expected to improve the health of women and infants, through some safe motherhood advocates questioning the effectiveness of antenatal care in the control of maternal mortality (Deal, 1995). There is little doubt that maternal health education and instructions about the recognition of symptoms leading to obstetric emergences, usually given at antenatal sessions, can be life saving and reduce delay in seeking help (Munodawara, 1997). In highly fertile societies such as developing countries, the antenatal period offers an opportunity to address other health related issues in women of reproductive age (Carroli, 2001).

Counselling and voluntary screening for HIV, prevention of maternal to child transmission of HIV and the introduction of parturient to the use of insecticide treated bed nets have been successfully integrated into antenatal care. Further, antenatal care provides an opportunity to obstetricians and midwives for prevention and early detection of maternal conditions such as anaemia, hypertension and other medical conditions affecting maternal health. No matter how well intended health programme may appear, clients, attitude remains vital for their successful inception and sustenance (Department of Health, 1993; Abrahams, 2001).

Lack of confidence in the changes and social issues have impeded the general acceptance and implementation of FANC in many developing countries including Nigeria. Even health care providers initially questioned aspects of FANC and its place in Sub — Saharan Africa (Ekele, 2003). The reception of FANC by severe Sub — Saharan African countries, although the implementation of FANC in Sub — Saharan Africa remains sub-optimal, donor agency driven, not widespread and associated with poor compliance to guidelines (Nyako, 2006).

Sustainable funding, Socio-cultural barriers and social mobilization seem to affect the full implementation of FANC in sub — Saharan Africa. In a study, 70% of the parturient did not desire a reduction in the number of their antenatal visits to four despite being assured of the safety to such a reduction. This is about three times the number in a previous study comparing FANC and traditional ANC in the United Kingdom, in which 26% of apparently eligible women refused to participate because they did not want to have fewer antenatal visits (Brown, 1970). Dissatisfaction with Lack of confidence in the changes and social issues have impeded the general acceptance and implementation of FANC in many developing countries including Nigeria. Even health care providers initially questioned aspects of FANC and its place in sub-Saharan Africa (Ekele, 2003).

The reception of FANC by several sub-Saharan African countries, although the implementation of FANC in sub-Saharan Africa remains sub optimal, donor agency driven, not widespread and associated with poor compliance to guidelines (Nyako 2006). Sustainable funding, socio-cultural barriers and social mobilization seem to affect the full implementation of FANC in sub-Saharan Africa.

In a study, 70% of the parturient did not desire a reduction in the number of their antenatal visits to four despite being assured of the safety to such a reduction. This is about three times the number in a previous study comparing FANC and traditional ANC in the United Kingdom, in which 26% of apparently eligible women refused to participate because they did not want to have fewer antenatal visits (Brown 1970). Dissatisfaction with fewer visits is shared by some women in both developed and developing countries (Baldo, 2001).

Most patients who desired a reduction in the number of antenatal visits to four in the study did so because they felt it would be more convenient and cheaper. Convenient and cheaper antenatal care is part of the long term goals of the new antenatal care model. According to WHO (2001), the new model at its inception may entail the reconstruction of clinic space to ensure individualized consultation, privacy and confidentiality and to permit care providers to see each patient in a defined location at each visit. Personnel training, the construction of side laboratories in the clinic area or relocating existing laboratories close to the clinics may similarly be required the initial costs of policy and programme development, provision of logistics and the cost of human resource development have so far impeded the realization of the full objectives of FANC in sub-Saharan Africa (Corea, 1985).

Women who preferred traditional ANC in this study did Not accept the view that four visit were adequate to achieve their desire in antenatal care. They did not believe that in four visits they can learn enough about pregnancy, know their service providers enough and that disease would be detected early enough some (67%) simply enjoyed antenatal sessions. There is little doubt that the motivation for some women to attend antenatal clinics is socialization (Baldo 2005). The psychosocial aspect of antenatal care is important as if influences patient’s evaluation of care, the effectiveness of antenatal visits and their health seeking practices (Abraham, 2001).

It may however, be difficult to justify the use of health provider’s time and resources merely for the provision of avenues for socialization (Meleis, 1997). Individualized consultation, privacy, confidentiality and being consistently seen by the same care provider in a definite location is designed in FANC to improve patient’s ease, their ability to obtain the information they require and their familiarization with their care providers. Myles (2003) observed that women in Ghana and Kenya were particularly impressed with FANC because the same care provider attended consistently to them at each visit.

According to RifKin (2000) the effectiveness of FANC in the early detection and prevention of common disease and causes of complication in pregnancy was an initial hurdle to the re-education in the number of antenatal visits at the time of it conceptualization. This has been extensively studies and it was concluded that traditional ANC and FANC are of equivalent effectiveness in the detection and prevention of disease in women of low risk.

According to WHO (2001) apprehension by patient about the anticipated inadequacy of FANC in the area of learning is addressed by the emphasis on health education, counselling and personalized consultation in the new model. Personalization and compartmentalization of care in FANC, however, increases the burden for human resources development and logistics in sub-Saharan African countries with already grossly under funded health services even in South Africa with one of the best resourced health programme. In sub Saharan Africa, FANC has been severely limited and full expansion prevented by financial constraints (Akinsola, 2000).

The study also shows that, almost 60% of those who took part in the study state that, financial difficulty is the main reason for not attending antenatal clinic. Other studies show that, oral knowledge on maternal health care result to lack of utilization of health care facilities (Fatusi, 2000). Antenatal care helps to promote and maintain health of women during pregnancy, also to educate mothers in various aspects of need such as nutrition, personal hygiene, family planning and environmental hygiene. These allow for recognition of “high risk cause and special attention given, which in turn reduce infant mortality” (Stanhope 2002). Antenatal care focused on evidence based as it goal directed action: It is centred on family care, it is focused on quality care. Its care is given by skilled health providers to promote awareness, the sociology of care in the aspect of child bearing, and the influence that these may have on the children. To recognize deviation from the normal and provide management or treatment as required to support and encourage a family healthy psychological adjustment to child bearing, to prepare the women for labour lactation, and the subsequent care of her child.

Types of antenatal care

Olise (2007) sees antenatal care into two phase, these are:

The first is the initial visit to the health facility.

The second is the subsequent visit to the health facility.

Initial visit

According to Olise (2007), the initial visit is also called the booking visit. Ideally, booking should occur not later than 18 weeks of gestation so that appropriate interventions can be affected where indicated. In Africa, however, pregnancy is largely a family secret till it can no longer be concealed. This, it is often claimed is to avoid giving evildoers the opportunity to harm the pregnancy. Activities during the booking visit include obtaining a history, physical examination and carrying out further investigations. (Cowan 1995).

History (under initial visit)

Physical examination Investigations

History

According to Rifkin (2000) the health worker is expected to document essential information on the client by writing the name age, address, next of kin, marital status and occupation, social history like the partner’s occupation, her own smoking or drinking habits should be noted. Consumption of alcohol and smoking are detrimental to the foetus and the pregnant woman should be advised to stop or at the least drastically reduce the intake of both substances. The date of commencement of the j last menstrual period is take so, too, is the regularity of the periods and the use or previous use of any contraceptive device especially intrauterine device. According to Abraham (1992) previous obstetric history is also noted. Especially;

Number of previous pregnancies and deliveries with dates.
History of still births
History of mid trimester abortion
History of post partum haemorrhage
Birth weight of other children especially if they are of low birth weight or too large (over 4.5 kg)
History of toxaemia of pregnancy
Post surgical history

Physical examination

According to Ailender (2001), the pregnant woman is weighed and the height measured, any deformity including unsteady joint should also be noted the breast is examined for any abnormal mass and inverted nipples. The booking blood pressure is recorded to act as a benchmark for subsequent readings where qualified man power is available, pelvic examination is recommended. After the first trimester, the uterus can be palpated on abdominal examination. As the pregnancy advances, the uterine fundus increases in height. Depending on the age of the pregnancy, the person and presentation may be determined.

Investigation

According to Munodawafa (1997), it is routine to perform certain laboratory and other investigation. They include;

Blood group
Genotype
Urine sugar
Urine protein
HIV screening e.t.c.

Not all these test may be available in primary health care facilities and so may have to be carried out elsewhere with advance technology, facilities for ultrasound scanning are increasingly available in urban settlement. Scanning is not yet a primary health care requirement in developing countries

The subsequent visit

This is the second type of antenatal care.

According to Chege (2005) after the initial visit, which is also know as booking visit, the frequency of subsequent visits depend on the history of the pregnancy. In the absence of specific risk factors, the expectant mothers are recommended to come for prenatal visit:

Every four weeks till 28 weeks. Every two weeks until 36weeks

Every week until the commencement of labour. At each visit, the weight, blood pressure and urine test are, measured/done. For most women, about 10 kg is gained during pregnancy, mothers should be asked of foetal movement. The haemoglobin is repeated at 30 and 36 weeks and thereafter, the engagement of the head should be checked. As mentioned earlier, antenatal care provides the opportunity for helping the pregnant women cope with the problem of pregnancy and to prepare her for safe child birth. Health education both in group and on one to one basis is vital (Change, 2005)

Objective of antenatal care

According to Abraham (1992), the following are the objective of antenatal ca these are:

To promote, and maintain the health of pregnant women so that they may deliver safely (Rifikin, 2000).
To detect or predict complications of pregnancy as early as possible so as to institute a preventive measure including referral (Davis, 1983).
To give health education to pregnant mothers which will prepare them for labour and successful lactation (Ejebe, (20007).
To encourage pregnant women to eat well through adequate nutrition and also through their effort in cooking balanced diet (Ailender 2001).
To decrease and or remove anxiety and fears usually associated with pregnancy and in particular the first pregnancy (Cowan 1995).
To attend to under 5 children who accompany their mothers to the clinic. (Myles, 2003).
To teach mothers personal hygiene and environmental sanitation. (Olojoba, 2009).
To detect high risk pregnancy and take appropriate measures (Enkin, 1995).
To reduce infant and maternal mortality and morbidity (Akinsola, 2000).
To promote appropriate utilization of health activities in the health centre for mothers and child care. (WHO, 1975).

Applicable methods of antenatal care

According to Fatusi (2000), the following are the applicable method of antenatal care, these are;

Health education
Immunization against tetanus
Other preventive measures

Health education

According to WHO (1975) this is as important as the examination to the mother. As well as guidance on her own diet, the mother should be given instruction in baby and child care the importance and the length of breast feeding necessary for the child should be stressed. Other useful topics to discuses are the importance of child spacing, the dangers of unsafe abortions, and methods of family planning. In all these discussions it may prove helpful to include fathers, elders in the family and the community. Opportunities for health education can be created through home visits, community or club meetings, or has one to one talks in clinics. Discussions in small groups are always more effective than lectures. With time and experience of working in an area one can develop insight into people’s knowledge, beliefs and attitudes, the type of health message that is received best, the most effective methods of health education and so on.

Immunization against tetanus

According to Bhatia (1995) neonatal tetanus is a common cause of death in many rural areas. In spite of the growing popularity of the western type of medicine, a large proportion of babies are still delivered at home and this practice may continue for many years to come. Under such circumstances, antenatal measures for protecting the baby against tetanus in the newborn period are essential (Peter, 2007)

Immunization of the mother during the antenatal period with tetanus toxoid produces a high level of antibody in her blood, which is sufficient to protect the baby from tetanus at birth. Hence in areas with a high incidence of neonatal tetanus the mother should be immunized with tetanus toxoid by means of three injections of 1 ml each, given at monthly intervals during the latter half of pregnancy. If previously immunized, one booster injection in the last trimester will provide adequate protection.

Other preventive measures

According to Myles (2003) anaemia is widespread in pregnant women in developing countries. Much of it is due to iron deficiency even though deficiency of folic acid also plays a significant role. In malarious areas there is an added risk of anaemia caused by the malaria parasite regular administration of iron (ferrous sulphate, 200mg) and folic acid (10mg), especially in the last trimester will ensure against deficiency. Regular anti-malarias, such as chloroquine 150 mg once a week, will not only protect the mother against anaemia of malarial origin but will also ensure adequate foetal growth.

Poor utilization of antenatal services by pregnant women

According to Sikorski (1996), poor utilization of health care services is a major barrier to health which leads to high maternal mortality rate; mothers are educated to visit health facilities that can provide emergency obstetric care which is the best tool for reducing maternal mortality. It is estimated that, 60 to 80% of women deliver outside modern health facilities. Okojie (2005) noted in a study that, in the eastern part of Nigeria, it was found that, all 93% of rural mothers who had child birth or spontaneous abortion registered for prenatal care, 49% delivered at home under the care of TBAs. Similarly, in a study of 377 women who delivered before arrival at the hospital, 65% of the women have been delivered by TBAs, while 7.3.7% had sought help from TBA as well.

W.H.O, UNICEF, and UNFPA promote the training of TBAs as in order to bridge the gap until all women and children have access to acceptable professional modern health care services (WHO, 1978).

Management of poor antenatal care

According to Stanhope (2002) the following are ways to manage poor antenatal care these are;

There should be public enlightenment on the important of antenatal care. It helps to reduce maternal mortality, prolong labour and also to treat pregnant mothers against diseases.
Health education on factors associated with at risk pregnancy. These factors include severe malaria, swelling legs, bleeding. These are condition that needs special attention (WHO 1978).
There should be trained personnel at the health centre and hospitals such as the nurses and other health personnel and also provision.

References

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