Introduction
Despite the need and availability of modern health care facilities, their utilization by pregnant women is alarmingly low, leading to the high rate of maternal morbidity and mortality. In most Nigerian communities, expectant mothers prefer to put to birth at homes and this has implications on the health of mothers and infants. It is not uncommon to hear or find cases of maternal complications and subsequent death due to the ineffective utilization of modern health care facilities by expectant mothers (Iyaniwura & Yussu, 2009).
The high rate of deaths of women during pregnancy, childbirth or in the immediate postpartum period is due to different influencing risk factors. These are directly linked to socioeconomic, reproductive and health service factors. The general socioeconomic status of mothers, ability of women to manage resources and make independent decisions about their health has an impact on reduction of maternal mortality (Addai, 2010).
Lack of education and poor knowledge of maternal health care has contributes to delays in seeking care during pregnancy and child birth. Poverty is one of the major health determinants. Poor mothers are at high risk of developing pregnancy related complications, because they are not financially able to pay for the required services (United Nations Population Fund [UNFPA], 2014).
Almost, all maternal deaths that occur in low and middle-income countries are mainly among the poorest of the poor (Adedotun, 2010). In addition, lacks of access to emergency obstetric care and delay for emergency referral have contributed to high maternal mortality in the area. Obstetrics complications are able to be treated in health institutions that are sufficiently equipped with supplies medications and fully staffed with capably trained health professionals but in the area of study such facilities are not available thereby subjecting pregnant women to their faith which in most cases result in deaths (World Health Organisation [WHO], 2009)
Indeed, all pregnant women are at risk of developing complications during any time of their pregnancies, deliveries and postpartum periods. Most of the obstetric complications cannot be predicted but can be prevented and treated if women have access to appropriate modern health care services cares.
Conceptual framework
According to the United Nations (2011), non-utilization of modern healthcare services among pregnant women in many low and middle-income countries has been a major public health issue with sub-Saharan African and South East Asia recording the lowest level of utilization of modern healthcare services by pregnant women. Titaley, Hunter, Heywood and Dibley (2010) stated that the utilization of modern healthcare services from a medically trained provider is an essential service for pregnant women aimed at ensuring healthy pregnancy outcomes and improving survival rates of the newborn.
The Partnership for Maternal Newborn and Child Health (2016) highlighted that effective utilization of modern healthcare services links the pregnant woman and her family to formal health systems, enhances the chance of using skilled birth attendants at delivery and contributes to good health throughout pregnancy. However, the proportion of women utilizing modern healthcare services in Sub-Saharan African and South East Asia is alarmingly very low leading to high maternal mortality ratio. This unappealing situation of non-utilization of modern healthcare services has been traced to some social dynamics, barriers and the fact that use of modern healthcare services is not adequately understood which calls for adequate attention (Yared & Asnaketch, 2012).
Prevalence of non-utilization of modern healthcare service by pregnant women in Nigeria
Studies revealed that non-utilization of modern healthcare services is higher among the poor, rural, unmarried and less educated women. Osungbade, Shaahu and Uchendu (2011) stated that non-utilization of modern healthcare services varied significantly with regards to economic status, educational attainment, residence, geographical locations, age and marital status.
The 2013 National Demographic and Health Survey, stated that up to 61% of women age 15–49 who had a live birth in the 5 years preceding the survey received antenatal care from a skilled provider, but skilled attendance at birth remains low at 38% and only 36% of births in Nigeria are delivered in a health facility. This under-utilization may vary from region to region in Nigeria. In Northern Nigeria, 58.7% had antenatal care, 17% delivered in a health facility with 22.3% skilled attendance at delivery. In Southern Nigeria, 72% had antenatal care, 43% delivered in a health facility with 51% skilled attendance at delivery (Babalola & Fatusi, 2009).
Majority of women in developing countries receive almost no postnatal care. For example, in very poor countries and regions, such as those in the sub-Saharan Africa only 5% of women receive postnatal care. Findings by the World Health Organisation (WHO) (2009) show that a woman living in Sub-Saharan Africa has one out of 16 chances of dying after childbirth.
Contributory factors to non-utilization of modern healthcare services by pregnant women
The Nigeria, research shows that the main factor contributing to non-utilization of modern health care services include:
- geographical region;
- husband’s polygamy status;
- woman’s literacy level and
- place of residence.
Geographical region
Studies in other have shown regional differentials in the non-utilization of modern healthcare services. Women who resided in Northern part of Nigeria remained highly disadvantaged with increased odds of non-utilising modern healthcare services compared to their counterparts in Southern Nigeria. The non-use of modern healthcare services could be attributed to the lack of these services or lack of easy access to them in these geographic locations. Also, the overall poor health development, infrastructure, a lack of security, illiteracy, poor and with low socio economic status were found to be major contributory factor (Audu, Takai & Bukar, 2010).
Husband’s polygamous status
Edward (2011) stated that women whose husband has more than one wife has a higher risk of non-use of modern healthcare services among woman whose husbands had more than one wife. The author stressed that women need support from their husbands to utilize modern healthcare services. For women in a polygamous relationship, her husband’s attention is divided between his wives, and therefore he would have less time to pay attention to the needs of each of his wives.
Woman’s literacy level
Yared and Asnaketch (2012) stated that illiterate mothers had the worst maternal health outcomes compared to their literate counterparts in terms of access and utilization of modern healthcare services. It is also unlikely that illiterate women would seek out quality modern healthcare services; they also lack the essential knowledge that might help them use health care inputs that offer better maternal health care services. The women’s level of education has also being found to be a risk factor for the non-utilization of modern healthcare services. Lack of education hinders women from receiving, seeking and communicating information concerning their health that could help prevent maternal and newborn deaths.
Place of residence
Arthur (2012) stated that women living in rural areas were less likely to use modern healthcare services, compared to their counterparts in urban areas. Non-use of modern healthcare services is significantly higher among rural women compared to their urban counterparts. Other factors such as higher quality of care, shorter walk-time to health facilities and the woman’s education were significant determinants of routine use of modern healthcare services. Women who live in rural area travel long distances to reach modern healthcare services. Thus, distance to maternal health services and transportation problems may greatly reduce access to modern healthcare services in rural areas.
Effects of non-utilization of modern healthcare services by pregnant women
Pregnancy is associated some delicate health conditions that needs adequate care. Lewis (2013) stated that non-utilization of modern healthcare services during pregnancy exposes pregnant women to some complication which include, but are not limited to:
- High blood pressure
- Gestational diabetes
- Preeclampsia
- Preterm labour
- Pregnancy loss
High blood pressure
High blood pressure, also called hypertension, occurs when arteries carrying blood from the heart to the body organs are narrowed. This causes pressure to increase in the arteries. In pregnancy, this can make it hard for blood to reach the placenta, which provides nutrients and oxygen to the foetus. Reduced blood flow can slow the growth of the foetus and place the mother at greater risk of preterm labour and preeclampsia. Women who have high blood pressure before they get pregnant will continue to have to monitor and control it with medications throughout their pregnancy (American College of Obstetricians and Gynecologists, 2011).
Gestational diabetes
Gestational diabetes occurs when a woman who did not have diabetes before pregnancy develops the condition during pregnancy. Normally, the body digests parts of food into a sugar called glucose. Glucose is the body’s main source of energy. After digestion, the glucose moves into your blood to give your body energy. To get the glucose out of the blood and into the cells of your body, your pancreas makes a hormone called insulin. In gestational diabetes, hormonal changes from pregnancy cause the body to either not make enough insulin, or not use it normally. Instead, the glucose builds up in your blood, causing diabetes, otherwise known as high blood sugar (Leeman & Fontaine, 2008).
Over time, high glucose levels can cause serious health problems, such as heart disease, vision problems, and kidney disease. Managing gestational diabetes, by following a treatment plan outlined by a health care provider, is the best way to reduce or prevent problems associated with high blood sugar during pregnancy. If not controlled, it can lead to high blood pressure from preeclampsia and having a large infant, which increases the risk for caesarean delivery (Centers for Disease Control and Prevention, 2013)
Preeclampsia
Preeclampsia is a serious medical condition that can lead to premature delivery. Its cause is unknown, but some women are at an increased risk. Risk factors include, first pregnancies, preeclampsia in a previous pregnancy, existing conditions such as high blood pressure, diabetes, being 35 years of age or older, carrying two or more foetuses and obesity (American College of Obstetricians and Gynecologists, 2011).
Preterm labour
Preterm labour is labour that begins before 37 weeks of gestation. Any infant born before 37 weeks is at an increased risk for health problems, in most cases because organs such as the lungs and brain finish their development in the final weeks before a full-term delivery (39 to 41 weeks). Certain conditions increase the risk for preterm labour, including infections, having a shortened cervix or previous preterm births (American College of Obstetricians and Gynecologists, 2011).
Pregnancy loss/miscarriage
Miscarriage is the term used to describe a pregnancy loss from natural causes before 20 weeks. Signs can include vaginal spotting or bleeding, cramping, or fluid or tissue passing from the vagina. However, bleeding from the vagina does not mean that a miscarriage will happen or is happening. Women experiencing this sign at any point in their pregnancy should contact their health care provider. The loss of pregnancy after the 20th week of gestation is called a stillbirth. In approximately half of all reported cases, health care providers can find no cause for the loss. However, health conditions that can contribute to stillbirth include chromosomal abnormalities, placental problems, poor foetal growth, chronic health issues of the mother, and infection. Read more about health conditions and lifestyle factors that can increase the risk for stillbirth (American College of Obstetricians and Gynecologists, 2011).
Measures to promote the utilization of modern healthcare services by pregnant women
To promote the utilization of modern healthcare services by pregnant women as suggest by Ajayi and Osankinle (2013) include:
- Establish or strengthen national policies: A national policy and locally adapted guidelines must be in place to protect the rights of all women, regardless of their socioeconomic status or place of residence, to access modern healthcare services.
- Strengthen the quality of modern healthcare services: This includes promoting evidence based guidelines and standards for focused antenatal care. There should be adequate supplies and logistics for effective antenatal care including regular availability of syphilis and HIV testing kits and essential drugs and equipment.
- Improve integration of antenatal care with other programmes: To maximise opportunities for pregnant women, antenatal services should take advantage of existing programmes, especially those with outreach activities targeting women of childbearing age. This is especially important in settings where antenatal care coverage is low.
- Reduce barriers to accessing care and reach out to women without access: Utilisation of modern healthcare services should be encouraged by reducing barriers to access, such as user fees, limited opening hours, long travel distances and waiting times.
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