|Year : 2015 | Volume
| Issue : 3 | Page : 103-108
Patterns of utilization of orthodox and/or traditional healthcare services among pregnant women and mothers of under-five children in a rural community: Case study of Njaba, Imo State, Nigeria
Kenechi Anderson Uwakwe, Irene Adanta Merenu, Chukwuma Bonaventure Duru, Kevin Chiekulie Diwe, Henry Naemeka Chineke
Department of Community Medicine, College of Medicine, Imo State University, Owerri, Nigeria
|Date of Web Publication||10-Nov-2015|
Kenechi Anderson Uwakwe
Department of Community Medicine, Imo State University Teaching Hospital, Orlu, Imo State
Background: It has been stated that poor utilization of quality reproductive health service continues to contribute to maternal morbidity and mortality in Nigeria. Objective: The objective was to investigate the pattern of orthodox and/or traditional healthcare utilization among pregnant women and mothers of under.five children in Njaba and associated factors. Materials and Methods: A. cross.sectional survey of 422 women using multi.stage sampling, data collection instrument was a semi.structured interviewer.administered questionnaire. Data were analyzed with SPSS. (16.0) and Mathcad 7 professional. Frequency distributions and percentages were tabulated; Z.test was applied as a test of significance, and confidence intervals. (CIs) calculated. P < 0.05 was considered significant. Results: Ante.natal choice of care for 83.65% of them was orthodox healthcare, while 11.37% used traditional healthcare. Experienced/trained staff. (Z-score = 13.64, =0.000 and CI = 0.41–0.65) and neat environment. (Z-score = 13.98, =0.000 and CI = 0.45–0.69) were statistically significant reasons why the women preferred orthodox healthcare, whereas, good staff attitude. (Z-score = 12.57, =0.000 and CI = 0.62–0.80) was a statistically significant reason why some preferred traditional healthcare. Among the respondents who had delivered previously, 85.83% of the 374 deliveries were in orthodox healthcare facilities, while 14.17% were in traditional healthcare facilities. Conclusions: Majority used orthodox healthcare facilities because of experienced staff and neat environment, while some used traditional healthcare facilities due to better staff attitude. Attitudinal change in the orthodox facilities and training for traditional healthcare personnel are recommended.
Keywords: Njaba, orthodox health care, pregnancy, traditional health care, utilization
|How to cite this article:|
Uwakwe KA, Merenu IA, Duru CB, Diwe KC, Chineke HN. Patterns of utilization of orthodox and/or traditional healthcare services among pregnant women and mothers of under-five children in a rural community: Case study of Njaba, Imo State, Nigeria. Sahel Med J 2015;18:103-8
|How to cite this URL:|
Uwakwe KA, Merenu IA, Duru CB, Diwe KC, Chineke HN. Patterns of utilization of orthodox and/or traditional healthcare services among pregnant women and mothers of under-five children in a rural community: Case study of Njaba, Imo State, Nigeria. Sahel Med J [serial online] 2015 [cited 2019 Oct 15];18:103-8. Available from: http://www.smjonline.org/text.asp?2015/18/3/103/169283
| Introduction|| |
The health and survival of a pregnant woman depend in part on the availability, accessibility and utilization of quality health care in terms of antenatal care (ANC), emergency obstetrics care, and skilled provider at delivery. It had been stated that poor utilization of quality reproductive health service continues to contribute to maternal morbidity and mortality in Nigeria,, hence, an assessment of the choice of healthcare delivery during pregnancy in our rural populace is necessary. Maternal mortality rate estimate in Nigeria though has dropped to 224 deaths/100,000. Further reduction is still desirous. Adequate ANC and skilled obstetric assistance during delivery are important strategies that significantly reduce maternal mortality and morbidity.
The available options of this reproductive health service for a pregnant woman in the Nigerian context would be orthodox, which includes hospitals (public, private, and faith-based), maternity clinics, and primary health care centers; or traditional, which includes delivery by untrained traditional birth attendants (TBAs)/village midwives, herbalists, and healing homes.
Studies have assessed the utilization of both types of healthcare services, and reasons for their use,,, however, they did not compare the outcome of utilization of their services in terms of complications of delivery and none was from the study area. Other studies assessed the utilization of one of the available options during pregnancy/delivery.,,,,,
This study, therefore, sought the use of orthodox and or traditional healthcare services among women of reproductive age during pregnancy in Njaba Local Government Area (LGA), the factors responsible for their choice and the outcome.
| Materials and Methods|| |
Setting and subject
Njaba is an LGA of Imo State, Nigeria. Nnenasa is its headquarter. It has an area of 84 km 2 and a population of 145,110 as at the 2006 census. About 80, 600 out of the total population are females. It has 11 wards and about 16,500 households.
It has stores of fossil fuel and solid minerals, like precious stones. The area is also rich in cashew, palm oil, cocoa, guava, and oranges. Njaba is in the tropical rainforest belt of Nigeria. The people are predominantly farmers and traders.
This study was carried out among pregnant women, and mothers of under-five children in Njaba LGA, women outside this age group and those who did not meet the criteria or refused consent were excluded.
Study design and sampling
The research utilized a case study approach.
A sample of 440 subjects was recruited for the study. The number was determined using the Cochrane formula: n = z2 pq/E2 and P of 0.97 obtained from a past study that is, the proportion of childbearing women who utilized orthodox and traditional delivery centers in Ibadan.
A four-stage sampling technique was used for this study.
At first stage, simple random selection of 8 out of the 11 electoral wards by ballot. At the second stage, an autonomous community was randomly selected from each of the 8 wards by ballot. At the third stage from each of the autonomous communities, 55 households were selected purposively from the most populous community (in autonomies with more than one community) or from the most populous village (in single community autonomies) starting from the major market, moving in the direction with higher concentration of houses and studying one eligible woman per household. If the 55 was not completed, the other direction was also sampled. Finally, from each household, the youngest eligible woman was selected and interviewed if more than one, but if none the household was skipped.
Instrument and method of data collection
Semi-structured interviewer-administered questionnaire was used for data collection. The questionnaire obtained information on: Socio-demographic/economic parameters, knowledge of types of healthcare services, healthcare service of choice during pregnancy, reason (s) for healthcare service of choice, outcome of the choice of healthcare used during pregnancy. Data were collected between September and November, 2013.
Two research assistants were trained on questionnaire translation and administration with the aid of an interpreter who helped in back translation of the questionnaire.
The questionnaire was pretested among 30 women of reproductive age group in Umuna Community, Orlu LGA., (who were not part of the study population) and amended as appropriate.
Informed consent was obtained from participants and refusal to participate attracted no consequence, and permission was also sought from affected community heads. Data were anonymous and important findings would be disseminated appropriately. Ethical approval to conduct this study was obtained from the Institution's Research and Ethics Committee.
Some aspect of the data depended on recall memory.
Method of data analysis
Data were analyzed using statistical Package for Social Sciences for windows (Version 16.0. Chicago, SPSS Inc.) and Mathcad 7 Professional (Version 9. Mathsoft Inc.). Frequency distribution and percentages of relevant variables were tabulated. Z-test for difference between proportions was used as a test of significance, and confidence intervals (CIs) calculated. P < 0.05 was considered significant.
| Results|| |
Four hundred and forty questionnaires were administered, but after cleansing 422 (95.45%) were fit for analysis.
Socio-demographic profile of the respondents.
About half (58.06%) of the 422 respondents were 45 years and above as shown in [Table 1]. Two hundred and eighty six (62.8%) were married, while 16 (3.79%) were single. They were mostly Christians, 407 (96.45%), while 15 (3.55%) were traditional religion practitioners. Igbo was the predominant ethnic group 416 (98.58%), a high proportion (92.42%) had some level of formal education and majority were traders 154 (36.49%) and farmers 91 (21.56%).
Patterns of utilization of orthodox and/or traditional healthcare services.
About half (55.92%) of the study population was comprised of women who had delivered within the past 5 years, while 186 (44.08%) were presently pregnant. Majority (88.63%) had delivered previously while 48 (11.37%) were primiparas.
The choice of care during pregnancy for 353 (83.65%) of the respondents was orthodox healthcare only, this included hospitals, maternities, and primary health care facilities. Only 48 (11.37%) used traditional healthcare only, which included untrained TBAs/village midwives, herbalists, and healing homes, whereas 21 (4.98%) of them used both.
The content of care for respondents that received orthodox healthcare included physical examination (100%), drug prescription (98.93%), counseling/moral support (70.86%), urine testing (54.01%), blood tests (37.70%), ultrasound scan (34.22%), and others services (13.37%). For the respondents who received traditional healthcare, the content of care included physical examination (100%), counseling/moral support (69.57%), urine testing (50.72%), drug prescription (39.13%), blood tests (8.70%), and other services 21.74%.
The most prevalent reason for the use of orthodox health care was their experienced/trained staff as indicated by 98.40% of the 374 respondents (353 who used only orthodox and 21 who used both), while cheaper cost was the least reason (6.15%). For traditional healthcare the most prevalent reason was good staff attitude as indicated by 84.06% of the 69 respondents (48 who used only traditional and 21 who used both), while neat environment was the least reason (39.13%).
Good staff attitude was a statistically significant reason why some women preferred traditional healthcare facilities during pregnancy, as 84.06% of its users indicated that as their reason against 13.37% of the users of orthodox healthcare facilities (Z-score = 12.57, P = 0.000 and CI = 0.62–0.80), whereas, experienced/trained staff among others, was a statistically significant reason for preference of orthodox care as indicated by 98.40% of its users against 44.93% of traditional care users (Z-score = 13.64, P = 0.000 and CI = 0.41–0.65) [Table 2].
|Table 2: Comparison of reasons for the choice between orthodox versus traditional healthcare during pregnancy|
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Inquiry on why the women did not use the alternative choice of healthcare revealed that of the 48 women who used only traditional healthcare, the following did not use orthodox healthcare for stated reasons: Prohibitive cost 41 (85.42%), illegal fees 35 (72.92%), untrained/inexperienced staff 11 (22.92%), lack of drugs/supplies 5 (10.42%), poor response/services 8 (16.67%). Whereas, of the 353 women who used only orthodox healthcare, the following did not use traditional healthcare for stated reasons: Lack of drugs/supplies 350 (99.15%), untrained/inexperienced staff 346 (98.02%), poor response/service 275 (77.90%), illegal fees 15 (4.25%), and prohibitive cost 4 (1.13%).
Three hundred and seventy four (88.63%) of the 422 respondents had delivered previously. 321 (85.83%) of the 374 deliveries were in orthodox healthcare facilities while 53 (14.17%) delivered in traditional healthcare facilities. 65 (17.38%) of the 374 women had complications, the most prevalent in descending order being: Puerperal sepsis 23 (35.38%); postpartum hemorrhage 16 (24.62%); obstructed/prolonged labor 15 (23.08%); stillbirth and retained placenta both 3 (4.62%) and others (including antepartum hemorrhage and laceration) 5 (7.7%).
| Discussion|| |
This study examined the reasons why a woman of reproductive age group would choose orthodox or traditional health care during pregnancy and the results or health outcome of such choice. From this study, women of the reproductive age group of 45–59 years made up slightly above half (58.1%) of the respondents, a similar study in southwestern part of the country reported 74.5% from the 31 to 45 years age group. The observation here could be as a result of rural-urban migration by the younger age groups. About 62.8% of them were married. 92.4% of the women had one form of education, or another. The most frequent educational attainment was secondary school (35.8%), which was in keeping with the aforementioned study where 82.3% had formal education and 29.9% with post-primary education was the most frequent.
Majority of the women (83.67%) used orthodox healthcare service only during pregnancy compared to 11.37% who used traditional healthcare service only. This is in keeping with the studies in Sagamu, Ogun  where 84.6% used orthodox while 9.7% used traditional and Ibadan North, Oyo  where 93.3 used orthodox while 6.7% used traditional healthcare services. This, however differs from the studies in Kumbotso, Kano  where 59% used orthodox healthcare, and Chanchangi, Niger where 84% of households interviewed utilized traditional healthcare services. In a study in Zimbabwe, on the use of orthodox and traditional health services, orthodox (medical) services was consulted 8 times more than traditional services.
The reasons which significantly favored the use of orthodox against traditional health care services during pregnancy in this study were the trained staff, the neatness of the environment, and close distance. The first two reasons are understandable due to the better quality of training of orthodox healthcare workers and the neatness of the facilities; however, the third factor could be due to the presence of a teaching hospital in a nearby LGA, and other orthodox healthcare facilities around. The necessity of training for TBAs has been stated by previous studies,,,, this will improve their knowledge and practice for better services and utilization. This is imperative as the 67th World Health Assembly has approved  the World Health Organization's (WHO's) Traditional Medicine Strategy 2014–2023, which aims to promote universal health coverage by integrating traditional and complementary medicine services into healthcare service delivery and home care. The use of traditional against orthodox healthcare services was significantly favored by good staff attitude and cheaper cost. This is a call on government and operators of orthodox health facilities for attitudinal change on the part of healthcare workers, as other studies in rural Southeastern Nigeria, Nkanu, Enugu, Oji-river, Enugu  and rural Southwestern Nigeria , had reported poor attitude of healthcare workers as one of the determinants of poor utilization of orthodox health facilities. In terms of cost, the economic factor has been earlier reported as one of the major barriers to the utilization of antenatal services in rural Kano, Northern Nigeria. Since orthodox healthcare as shown in this study offered a more inclusive range of services (including scanning for instance), it should be costlier, however, its utilization could be improved if the National Health Insurance scheme (NHIS) is made functional in the informal sectors and rural communities.
A good proportion of the women who received care from both facilities had general body examinations and counseling, but poor proportions, 37.7% for orthodox and 8.7% for traditional had blood tests (which included hemoglobin, blood group and retroviral screening), this latter observation is unpleasant in view of the possible implications.
Of the 374 women who had delivered previously, 85.83% of the deliveries were in orthodox, while 14.17% deliveries were in traditional facilities. This is in keeping with the Sagamu study, where 79.3% and 5.6% of deliveries were in orthodox and traditional facilities, respectively, but in contrast with a study in Enugu where 47.1% and 52.9% delivered in health (orthodox) institutions and outside health institutions, respectively. Preliminary report from the 2013 National Demographic and Health Survey (NDHS), states that 36% of deliveries in the country take place in health (orthodox) facilities, however, for the southeast which is the zone of the study area it is put at 78.1%, while Imo is 90.9%, the highest in the federation  and in keeping with the observation of this study. With respect to the traditional deliveries, the WHO has observed that TBAs can potentially improve maternal and newborn health at the community level though they are generally not trained to deal with complications. More so, TBA's continued attendance at home deliveries suggests their potential in influencing maternal and neonatal outcomes.,
It has been reported in Nigeria that the choice to deliver outside hospital settings could be motivated by varying factors like economic, social, physical, cultural, or institutional. So in our environment, in spite of any improvement in antenatal care and delivery services in the hospital/orthodox facilities, it should be expected that a reasonable fraction of women would deliver outside hospital/orthodox facilities or without skilled provider (doctor, nurse, midwife, and auxiliary nurse). This is exemplified by the 2013 NDHS report, in which the percentage of deliveries conducted by skilled providers varied from 11.3% in the North West to 82.5% in the southwest.
| Conclusion|| |
This study has shown that the majority of women of reproductive age in Njaba utilized orthodox health services for ANC and delivery while a low proportion still used traditional healthcare services. The major factors that determined the use of orthodox facilities were the experienced/trained staff and the neatness of the facilities, whereas the use of traditional facilities was influenced by the good staff attitude and cheaper cost. Thus, it is recommended that strategies be evolved to create attitudinal changes in healthcare workers of orthodox facilities by the operators to make them more patient-friendly. Conscious effort should be made by government at all levels to have free or subsidized antenatal and delivery services, likewise implementation of the NHIS at the informal sector and rural areas would help in payment for health services and reduce burden of health cost. The TBAs/village midwives should be encouraged and aided by all concerned to constantly upgrade their knowledge and skills and through trainings and re-training on safe and best practices. They should also participate in related seminars, lectures, and conferences to keep updated.
| Acknowledgment|| |
Special thanks to Chijioke Bright C. and Oluh B. Tochukwu for data collection, also to all our respondents.
| References|| |
Moore BM, Alex-Hart BA, George IO. Utilization of health care services by pregnant mothers during delivery: A community based study in Nigeria. J Med Med Sci 2011;2:864-7.
Federal Ministry of Health (Nigeria). National HIV/AIDS and Reproductive Health Survey. Abuja, Nigeria: Federal Ministry of Health; 2003.
Federal Ministry of Health (Nigeria). National HIV/AIDS and Reproductive Health Survey Plus. Abuja, Nigeria: Federal Ministry of Health; 2012.
Ewa EE, Lasisi CJ, Maduka SO, Ita AE, Ibor UW, Anjorin OA. Perceived factors influencing the choice of ante-natal care and delivery centres among childbearing women in Ibadan North, South-Western, Nigeria. Ethiop J Environ Stud Manage 2012;5:373-83.
Iyaniwura CA, Yussuf Q. Utilization of antenatal care and delivery services in Sagamu, south western Nigeria. Afr J Reprod Health 2009;13:111-22.
Onah HE, Ikeako LC, Iloabachie GC. Factors associated with the use of maternity services in Enugu, southeastern Nigeria. Soc Sci Med 2006;63:1870-78.
Okonkwo JE, Ngene JN. Determinants of poor utilization of orthodox health facilities in a Nigerian Rural Community. Niger J Clin Pract 2004;7:74-8.
Adamu YM, Salihu HM. Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria. J Obstet Gynaecol 2002;22:600-3.
Kabir M, Iliyasu Z, Abubakar IS, Asani A. Determinants of utilization of antenatal care services in Kumbotso Village, northern Nigeria. Trop Doct 2005;35:110-1.
Ofili AN, Okojie OH. Assessment of the role of traditional birth attendants in maternal health care in Oredo Local Government Area, Edo State, Nigeria. J Community Med Prim Health Care 2005;17:55-60.
Imogie AO, Agwubike EO, Aluko K. Assessing the role of traditional birth attendants (TBAs) in health care delivery in Edo State, Nigeria. Afr J Reprod Health 2002;6:94-100.
Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth attendants and village midwives. J Obstet Gynaecol 2004;24:5-11.
Odueze CJ. History of Njaba L.G.A ©2003. Available from: www.oocities. org\njabalga\historyoflga.html [Last accessed 2014 Aug 11]
Cochran WG. Sampling Technique. 2nd
ed. New York: John Wiley and Sons Inc.; 1963.
Itina SM. Characteristics of traditional birth attendants and their beliefs and practices in the Offot Clan, Nigeria. Bull World Health Organ 1997;75:563-7.
Winston CM, Patel V. Use of traditional and orthodox health services in urban Zimbabwe. Int J Epidemiol 1995;24:1006-12.
Ebuehi OM, Akintujoye IA. Perception and utilization of traditional birth attendants by pregnant women attending primary health care clinics in a rural Local Government Area in Ogun State, Nigeria. Int J Womens Health 2012;4:25-34.
Jimoh AA. Utilisation of antenatal services at the Provincial Hospital, Mongomo, Guinea Equatoria. Afr J Reprod Health 2003;7:49-54.
Akpala CO. An evaluation of the knowledge and practices of trained traditional birth attendants in Bodinga, Sokoto State, Nigeria. J Trop Med Hyg 1994;97:46-50.
World Health Organization. WHO Traditional Medicine Strategy 2014-2023. Geneva: World Health Organization; 2013.
Uzochukwu BS, Onwujekwe OA, Akpala CO. Community satisfaction with quality of maternal and child health service in South East Nigeria. East Afr Med J 2004;81:293-9.
Bawa SB, Umar US, Onadeko M. Utilization of obstetric care services in a rural community in southwestern Nigeria. Afr J Med Med Sci 2004;33:239-44.
National Population Commission. Nigeria Demographic and Health Survey 2013: Preliminary Report. Abuja, Nigeria: National Population Commission; 2013.
World Health Organization. Global Action for Skilled Attendants for Pregnant Women. Geneva: World Health Organization; 2004.
Falle TY, Mullany LC, Thatte N, Khatry SK, LeClerq SC, Darmstadt GL, et al
Potential role of traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr 2009;27:53-61.
Ahmed OA, Odunukwe NN, Akinwale OP, Raheem TY, Efienemokwu CE, Ogedengbe O, et al
Knowledge and practices of traditional birth attendants in prenatal services in Lagos State, Nigeria. Afr J Med Med Sci 2005;34:55-8.
[Table 1], [Table 2]