Introduction
Morbidity and mortality are on the increase among women of reproductive age in developing countries (WHO, 2004). This is as a result of complications arising from pregnancy and child birth. Each year, according to WHO estimation, over 500,000 women and girls die from these complications. About 99% of these deaths occur in developing countries with mortality ratio of 545 deaths per 100,000 life birth (NPHS, 2008).Nigeria accounts for about 10% of all maternal death globally and has the second highest mortality rate in the world after India. It is reported that for every woman that dies from pregnancy related causes, 20 to 30 more will develop short and long term damage to their reproductive organs resulting in disabilities such as obstetric fistulas, pelvic inflammatory diseases, and rupture of the uterus(Ogunyuyigbe and Laisu, 2007)
Childbearing is a key part of women’s lives and occur mainly in the adolescent and adult years. Maternal health therefore becomes a very important issue as this is also their most productive time when they strive to fulfill their potentials as individuals, mothers and family members and also as citizens of a wider community. At the individual level, poor health of the women causes lack of employment leading to poor income. This results in persistent poverty and lack of empowerment. Poor maternal health can also have high cost on the family in emotional health and economic terms. With this high maternal mortality and morbidity, the survival and well being of the children will be greatly affected and also contribute to poor family relationships. More so, direct medical cost, loss of income and other economic contributions potentially puts the family in economic distress (UNFPA, 2009)
Studies have shown that majority of maternal death and disabilities can be prevented through early and timely access to the utilization of quality maternal health care services (Basoilola and Fatus, 2009).
The different maternal health care services which have been found to greatly reduce maternal morbidity and mortality are antenatal services, postnatal services just to mention but a few. The value of utilizing modern maternal health care services can hardly be over emphasized. It may be the only opportunity available to a woman to be seen by a skilled health worker. The reduction of maternal mortality requires early detection of high risk pregnancies through appropriate antenatal care at community level and the existence of a mechanism to ensure that timely access to referral facilities is possible.
Conceptual framework
High maternal morbidity and mortality rate is a huge public health problem in the developing countries of the world, including Nigeria. With an estimated 52,000 annual deaths, Nigeria accounts for about 10% of all maternal deaths, globally, and has the second highest mortality rate in the world, after India. It is also reported that, for every women that dies from pregnancy-related causes, 20 to 30 more will develop short- and long-term damage to their reproductive organs resulting in disabilities such as obstetric fistula, pelvic inflammatory disease, a ruptured uterus, etc (World Health Organization (WHO), 2007; Shiffman and Okonofua, 2007).
Despite the existence of national programs for improving maternal and child health in Nigeria, maternal mortality and morbidity continue to be high and studies suggested that the majority of maternal deaths can be prevented or reduced if women had access to, or visited maternal health services during pregnancy, childbirth and the first month after delivery (Dayaratna, 2000; WHO, 2004; Federal Ministry of Health, 2005). However, many women in developing countries do not have access to maternal healthcare services and it is reported that the use of such services remain low in Sub-Saharan Africa including Nigeria (Babalola and Fatusi, 2009); where only 58% of women have attended at least one antenatal clinic during pregnancy, 39% of births are attended to by a skilled professional, 35% of deliveries take place in a health facility and 43.7% receive postnatal care (NDHS, 2008; WHO et al., 2012).
Maternal health care services are underutilized particularly among those who are in the greatest need despite the fact that they are available in most of the hospitals in Nigeria, though each hospital operates according to its own rules, regulations, policy and conditions of services depending on the available resources.
Mothers are expected to seek maternal health care before, during and after delivery in the hospital, but it was observed that a low number of women came to the hospital to fully utilize these services in the study setting despite the beneficial impact
Level of awareness of maternal health care services
The findings of the study carried out by Onasoga A. , Osaji T., Alade O & Egbuniwe M. (2013)in Bayelsa State revealed that majority of the respondents 182 (94.8%) were not aware of maternal health services and only a few actually knew the main services rendered at maternal health services.
Factors responsible for the under utilization of maternal health care services
- Family wealth index (FWI)
It is well recognized that increase income positively affect utilization of health care services (E.G, 2007; Tosu, 2009; Cited in Chakraborty et al; 2008). The cost of seeking health care may include cost for transportation, consultation fees, medications and other supplies. People or families with limited financial resources may have difficulty paying for such cost and are likely to be deterred from using maternal health care services (Gabrysh & Campbell 2009). This was illustrated by Thaddeus and maine (2010 cited in Gabrysh and Campbell 2009) when it was noted that hospital birth drastically declined in Nigeria when user fees was introduced in the 1980s.
Studies have shown that couples with good income are mere likely to utilize health care service. This is because greater wealth index makes it easier to bear the cost of health care. However various other studies have shown that women are less likely to utilize maternal health care service when they do not have personal control over finances (Defo, 2006, Furuta and Salway, 2006, Gage & Calixte, 2006) suggesting that an interaction between autonomy and family wealth produces health services utilization. Overall, women are more likely to use health service as their economic status and autonomy level increases (Totso, Eze and Essendi; 2009)
- Culture of the people
Many factors have led to increase maternal and peri-natal morbidity women expect a healthy outcome of themselves and babies and have less worries about complications. They are more concerned with the emotional aspect of the experience rather the dangers of remaining at home or going for a local massage during antennal period (Duke 2011). Despite the advent of antenatal services, most pregnant women still patronize traditional birth attendants (TBAS) and these group of people are greatly respected in the communities. They cling to ancient customs and traditions, some of which are harmful to the health of the individual and they do not have legal status yet they are respected in the communities, WHO (2004).
According to Gouglas (2010) education through schools, magazines, television, radio, poster, community mobilization and others will help to change their mentality towards health care. Most women of child bearing age still patronize TBAs because they believe that there are some rituals to be performed before the baby is born. In the Midwestern region, most women both in the rural and urban area still go for rituals before delivery. Oghenekaro (2011) carried out a study on women; 75% of them claim that their culture of studying moon as the fetus grows, rubbing the abdomen and part of the perineum with certain spices (ofe) and inviting the husband to pray for the unborn child using their feet to clean the abdomen still exist. And these people believe in these practices strongly.
- Beliefs
Fort and Voltero also found out that spiritual beliefs have an impact on the use of health care facilities. In many cultural groups including native Americans, Amish, Asian and others, using modern medical care is in direct conflict with traditional beliefs about the sources of health problems and illness.
People immersed in these beliefs may turn to a more traditional healer such as a curandos or acupuncturist for relief of their symptoms.
- Accessibility Of Health Care Services
The location and quality of services available are also important factors affecting maternal health care service utilization.
Proximity to a healthcare facility has been found to affect the use of MHCS especially in the rural areas. (Rahaman et al., 2013) as these facilities are usually located at long distances, for many lack of transport and /or consideration of the cost of transportation serves as mitigating factors to health care seeking.
In rural communities, lack of transportation and distances to an emergency room or a hospital can be important barriers to receiving prompt treatment. Local communities find it difficult to obtain and keep medical and dental practitioners specialty service such as pharmaceuticals and going to the doctor is out of the question for those who do not have universal health care or health insurance.
- Educational Status
Lopez (2012) stated “That the educational status of the couple should not pose any problem in her care rather it should help to broaden their knowledge towards achieving the best of care she needs”. Research in developing countries has consistently shown with schooling to be strongly and positively associate with utilization of MHCS (Elo, 2013; Mariam & Mitike, 2014; Rogan and Olvena, 2008; Fotso, Ezeh and Essendi; 2009; Kamal, 2009; Munsur, Atia & Kawahera, 2010). The higher a woman’s level of education, the more likely she is to utilize MHCS. Some studies have suggested that more educated women are better able to comprehend the importance of receiving prenatal care and are also more likely to know where to get it (Obermeyer & Potter 1991, Raghapathy, 1996).
- Science
You could have the money, the insurance and the health to undergo treatment for a health issue but still be influenced by a factor that would prohibit you receiving a health care service. For example, if you suffer from a condition that is fetal, there are limits to what science can do to help you. Thus, one other factor that influence health care service is whether a cure or treatment exist yet or not.
- Religion
Religion according to Joe Emofe is the art of worship in truth and in spirit several attempts have been made to find out the relationship between religion and traditional belief and their services. Some women believe that only those who have arranged the spirit that they worship that go to seek medical care. According to Mary Bradley, the only way to discourage such mortality from people in the community is to find out more about their religion and traditional beliefs. With this, the health care giver will be able to know the percentage of those with such religious beliefs and discourage those who still practice them. With this, the health care provider will be able to identify the dangers in such religious beliefs.
Mary Braddley (2006) agreed that religious beliefs of the people has affected their patronage of the health service and about 20% of women in rural communities still worship their idols that prevents them from utilizing the health facilities.
- Attitude Of Healthcare Providers
Most people complain that the attitude of healthcare giver discourage them from utilizing ANC during pregnancy; because of this day do not go for antenatal services when they are pregnant, Stephen (2010.
According to James (2007) the health professional and health worker especially the nurse should establish a good report with the client (nurse client relationship). The health worker must be approachable and flexible to inspire trust and confidence in the client. According to Margaret Myles (2009) the midwife and health workers attitude well determine the maximum satisfaction of the care giver to pregnant women rather than creating barrier in achieving health care. In a study carried out on the attitude of health workers towards clients/patients pilisiek and Froland revealed that social classification and more attention are given to the privileged ones in the society. Patient complain of lack of attention, raining of abusive words and many other ill behaviours by midwives. In fact many lives have been lost because of these behaviours.
This nonchalant attitude have been responsible for poor utilization of health care services especially in government own health institutions.
- Birth order
A strong relationship has been has been shown to exist between birth order and utilization of maternal health care services. (Wary et al., 2009; Elo,2013 ; Chakraburty et al., 2008 ). Due to uncertainty and the perception of risk associated with first pregnant,women are more likely to seek medical attention for 1st order births than subsequent ones. Moreover, having a larger number of children may cause resources constrain, which has been found to be negatively associated with maternal health care services use ( chakraburty et al.,2008). Alarger family also places more demand on a woman`s time thereby limiting her ability to access health care.
- Age
The age of an individual is important determinant of health care utilization. Actual need for care is the most important reason for increased care as we age (cockeham, 2007). Hospitalization occur more often for patients over 65+ (kronenfield, 2009). The over-age 65 cohort, use health care services 11.5 times more than any young age cuhiort in 2007 in the United State (National centre for Health Care Statisticss, 2005). There is a complex interaction with factors other than age in the utilization progress however, Calvin and Fan (2006) found that age plus public insurance and disability cause increased utilization and reed for health care.
Strategies to improve utilization of MCHs
According to Abebaw, Alemayehu and Mesganaw (2013) , improving utilization of maternal health care services can be achieved by improving community awareness and perception on skilled providers and their care by targeting women who prefer non-skilled providers and those who do not have any awareness; Safe motherhood education usingthe available communication networks in the rural communities and innovative informational campaigns and also ensuring the seamless performance of basic essential obstetric care facilities (health centers) .
Onasoga, Osaji, Alade and Egbuniwe (2013) were of the opinion that government should subsidize maternal health services in order to make it affordable, acceptable and available to women. Also nurses should encourage women of reproductive age to utilize maternal health by providing a welcoming and supportive attitude at all contacts.
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