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ORIGINAL ARTICLE
Year : 2015  |  Volume : 18  |  Issue : 3  |  Page : 109-115

Factors responsible for under-utilization of postnatal care services in Maiduguri, north-eastern Nigeria


1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Public Administration, Faculty of Management Sciences, University of Maiduguri, Borno, Nigeria
3 Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Borno, Nigeria
4 Department of Obstetrics and Gynaecology, State Specialist Hospital, Maiduguri, Borno, Nigeria

Date of Web Publication10-Nov-2015

Correspondence Address:
Idris Usman Takai
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, PMB 3452, Kano State
Nigeria
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DOI: 10.4103/1118-8561.169282

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  Abstract 

Background: In Maiduguri, the utilization of available postnatal care services is still very low. This may be influenced by demographic, socioeconomic, cultural, and obstetric factors among others. Objective: The aim of this study is to understand the current status of utilization of maternal postnatal health care services and identify factors responsible for under.utilization of available postnatal care services in Maiduguri. Materials and Methods: A. cross.sectional, questionnaire.based study was conducted involving 350 women in their reproductive age group. (15.49. years), who had delivered previously, residing in Maiduguri and who came to access any of the available maternal health care services at the State Specialist Hospital, Maiduguri over a 3.month period. The Chi.squared statistics and multivariate logistic regression analysis were used. Results: Out of the grand total of 350 questionnaires that were distributed during the study period, 18 questionnaires were excluded from analysis due to incomplete responses, 332 with complete responses were therefore analyzed, giving a response rate of 94.9%. The results showed that only 16.9% of the respondents attended postnatal care services within 42. days after delivery. Most of the mothers. (60.9%) were not knowledgeable about postnatal care services. A. very high proportion of participants. (69.4%) did not attend antenatal clinics, and over. 70% of the study population had delivered at home. The study has identified some factors that have an important influence on utilization of postnatal care services in Maiduguri. These included awareness of postnatal care services. (odds ratio. [OR] 12.04, 95% confidence interval. [CI]: 10.26, P =. 0.000), higher educational status of the woman. (OR 7.15, 95% CI: 5.19, P =0.000), lower parity. (OR 5.22, 95% CI: 3.21, P = 0.001) and marital status. (married woman.OR 3.44, 95% CI: 2.17, P =0.002). Educational attainment of the husband also significantly affected the respondents' seeking behavior of postnatal care. (OR 2.01, 95% CI: 1.13, P =0.042). Conclusion: Utilization of postnatal care services is quite low in Maiduguri. Socioeconomic and sociodemographic factors influenced the use of postnatal care services. Government should provide culturally acceptable health educational programs and expands maternal health care services into the communities for the better, effective and efficient health care delivery.

Keywords: Factors, Maiduguri, postnatal care services, under-utilization


How to cite this article:
Takai IU, Dlakwa HD, Bukar M, Audu BM, Kwayabura AS. Factors responsible for under-utilization of postnatal care services in Maiduguri, north-eastern Nigeria. Sahel Med J 2015;18:109-15

How to cite this URL:
Takai IU, Dlakwa HD, Bukar M, Audu BM, Kwayabura AS. Factors responsible for under-utilization of postnatal care services in Maiduguri, north-eastern Nigeria. Sahel Med J [serial online] 2015 [cited 2019 Oct 15];18:109-15. Available from: http://www.smjonline.org/text.asp?2015/18/3/109/169282


  Introduction Top


In Nigeria, the use of health facilities during delivery by pregnant mothers and postnatal care utilization is still very low, and maternal morbidity and mortality remains a public health problem.[1] Even though utilization of maternal health services is associated with improved maternal and neonatal health outcomes,[2] the 2013 National Demographic and Health Survey,[3] 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 and from state to state. In Borno state, North-Eastern Nigeria, up to 58.7% had antenatal care, 17% delivered in a health facility with 22.3% skilled attendance at delivery.[3]

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.[4] The recent findings by the WHO, United Nation International Children's Emergency Fund and United Nations Population Fund, show that a woman living in Sub-Saharan Africa has one out of 16 chances of dying after childbirth.[5] Postnatal care programs are among the weakest of all reproductive and child health program in the region. Studies have indicated that the factors that prevent women in developing countries from getting postnatal care were sociodemographic, socioeconomic, cultural, obstetrics and health system factors.[1],[4],[5]

According to the World Program of Action, postnatal care is regarded as one of the most important maternal healthcare services which is critical to the health and survival of a mother and her newborn.[4] Lack of postnatal care may result in impairments and disabilities or death as well as missed opportunities to promote healthy behaviors, affecting women, newborns, and children.[6]

Considering global and national interest in the Millennium Development Goals.[1],[4],[5] and Nigeria's high level of maternal mortality,[7],[8],[9],[10] the use of postnatal care services and the barriers to utilization of these services need to be investigated. Despite the fact that maternal postnatal health care utilization is essential for further improvement of maternal and child health little is known about the current magnitude of use and factors influencing the use of this service in Maiduguri. It is within this context that this study was carried out. It is hoped that the results of the study will improve policymakers' understanding of the determinants of maternal postnatal care utilization in Maiduguri and serve as an important tool for any possible intervention aimed at improving the low utilization of maternity care services in the country.


  Materials and Methods Top


This was a cross-sectional; questionnaire based study conducted among women of reproductive age (15–49 years) who had delivered previously, residing in Maiduguri and came to access any of the available maternal health care services in the Department of Obstetrics and Gynecology of the State Specialist Hospital (SSH), Maiduguri between February 1, 2012 and April 30, 2012. The SSH, serves as the biggest tertiary maternity and referral center owned by Borno state government. It also serves as training and research center for State School of Nursing and Midwifery and that of School of Health Technology. Patronage of the hospital is very high because of affordability and availability of all medical sub-specialties with personnel who are well vast in their various field of specialization. Permission to carry out the study was obtained from the research and Ethical Committee of the SSH Maiduguri. The minimum sample size was calculated using a standard formula for known population size for a cross-sectional study; the Yamane Taro's formula,[11] given as.



Where n = sample size of adjusted population,

N = population size and

e = accepted level of error taking alpha as 0.05.

The estimated number of women of reproductive age seen in SSH Maiduguri monthly was estimated to be about 2500 (from the Department of Statistics SSH). Substituting this figure into the formula above, a sample size of 345 was obtained. However, to overcome risks of nonresponses or poorly answered questionnaires, 15 extra questionnaires were distributed, and this brought the sample size to 350 participants. It was anticipated that this sample size was representative of the study population, according to Yamane Taro's sampling guidelines. Sampling was done by convenience sampling through approaching all women who satisfied the inclusion criteria during the study period. The measure of validity and reliability of the structured questionnaire used for this study were carried out through pretesting using a few respondents. The questionnaire was however not translated in to the respondents vernacular, but assistance was given to some of the study participants in the interpretation and utilization of the questionnaires especially to those who could not read/and or write well. The questionnaire contained both closed-ended which are structured in a way that the respondents could have a choice or choices; and open-ended questions, to allow the respondents to fully express their minds or opinions so that more information that may not have been included in the closed ended questions could be obtained. The questionnaire was structured consisting of 30 questions in four sections. Section 1 included questions on demographic information (6 questions), section 2 is on knowledge and utilization (12 questions), section 3 is on socioeconomic factors (7 questions) and section 4 is on barriers to utilization of postnatal services (5 questions). The participants were fully and duly informed about the purpose of the study and an assurance of confidentiality stressed. Participants were also assured that their participation in the study was voluntary and that they could refuse to participate at any time during the interview. No personal identifying information was collected in an anonymous questionnaire. After full explanations to the participants regarding the study, questionnaires were handed over to those women who gave verbal consent to participate in the study. The nurse-midwives staff of the clinic assisted in data collection. The researcher, as well as the assistants, ensured that no woman was interviewed more than once by asking if they have been previously interviewed.

Data collected were entered into an IBM compatible PC and analyzed using SPSS version 17 (SPSS Inc., Chicago, IL, USA). The Chi-square test, univariate, bivariate and multivariate logistic regression analysis were employed in the treatment of data. A P < 0.05 was considered significant. Results were presented by simple statistical tables.


  Results Top


Out of the total of 350 questionnaires that were distributed during the study period, 18 questionnaires were excluded from analysis because of incomplete responses, 332 with complete responses were therefore analyzed, giving a response rate of 94.9%. [Table 1] summarizes the sociodemographic, reproductive and socioeconomic characteristics of the respondents. Most of the women (51.5%) were aged 25–34 years, mean age was 27.0 ± 5.9 years with a range of 15–45 years. Majority (92.8%) were married, 69.9% were respondents having more than one delivery; with a mean parity of 2; 66.6% were housewives, and up to 41.0% had no formal education. About 61.1% were Muslims, and the Kanuri/Shuwa constituted the highest (43.7%) ethnic group studied. The study also revealed that half of the husbands were educated to secondary school level and above, and a small proportion was nonliterate (11%). Up to 64.7% of the husbands were unemployed and were involved in different businesses and some others are in formal sector work or the civil service (35.3%).
Table 1: Sociodemographic and socioeconomic characteristics of the patients

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[Table 2] presents information about utilization of postnatal care services. Other variables that are addressed included mothers' attendance and nonattendance of postnatal services and the factors that influence the attendance of postnatal services. The results showed that up to 83.1% of the respondents did not attend postnatal care services and thus only 16.9% of them attended postnatal care services within 42 days after delivery. Mothers provided various reasons for attending postnatal services. The results showed that immunization of their babies (87.5%) as a major reason for attendance.
Table 2: Utilization of postnatal care services

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All women who did not attend postnatal care services were asked to give their opinions on barriers to access the postnatal care services in Maiduguri. [Table 3] lists these main barriers. It was observed that up to 69.4% of the participants did not attend antenatal care services and therefore had no opportunity to access health educative information from the service providers. This, therefore, most likely affected attendance at postnatal care visits. Lack of awareness of postnatal care by the women and their families ranked highest (60.9%) among the various opinions on the barriers to access the postnatal care services. About 39.1% had a wide range of reasons for not attending postnatal care services. Except the lack of awareness (P = 0.002), none of the perceived barriers, were statistically associated with postnatal care checkup.
Table 3: Perceived barriers to utilization of postnatal care services

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[Table 4] shows the association between attendance of antenatal services and utilization of postnatal services. Only 34 (10.2%) of the mothers attended both the antenatal care services and the postnatal care services. Meanwhile, 66 mothers (19.9%) attended antenatal but not postnatal services and 22 (6.7%) did not attend antenatal but attended postnatal care services. Two hundred and ten mothers (63.2%) attended neither antenatal nor postnatal care services. In the Chi-square analysis, the attendance of antenatal and postnatal services was independent (χ2 = 20.60; df = 6; P = 0.144).
Table 4: Relationship between the percentages of mothers attending antenatal care and postnatal care services

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[Table 5] shows the relationship between mothers' awareness and utilization of postnatal care services. Only 34 (10.2%) of the participants were aware and attended postnatal care services. Twenty two (6.7%) participants attended postnatal services despite the fact that they were not aware of the services. Meanwhile 96 (28.9%) of the mothers were aware of postnatal services but did not attend the services. In contrast, 180 (54.2%) of the participants were not aware of the services and did not attend the services. Significant association (χ2 = 35.20; df = 4; P = 0.002) was observed between mothers' awareness of postnatal care services and utilization of postnatal care services.
Table 5: Comparison between the awareness and attendance of postnatal care services

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An attempt was made to find out which of the sociodemographic factors were associated with postnatal care as shown on [Table 6]. The Kanuri/Shuwa ethnic group was more likely to have postnatal care than other ethnic groups (χ2 = 80.30; df; =3; P = 0.000). Other sociodemographic variables that were associated with postnatal care utilization included occupation (P = 0.001); marital status (P = 0.002); maternal age (P = 0.000); level of education (P = 0.000) and higher parity (P = 0.003). Women with husband educated up to secondary school level had a significantly greater chance of having postnatal care than those with illiterate husbands (P = 0.002). The husband occupation was associated with postnatal care uptake (P = 0.001). Husbands with formal sector job such as teaching or civil servant were more likely to have wives who attended postnatal care.
Table 6: Association between demographic/socioeconomic factors and postnatal care

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After the multivariate logistic regression analysis, the final model for the prediction of postnatal care utilization consisted of five variables; educational status of the woman and husband, awareness of postnatal care, marital status (married woman), and women with children less than five (lower parity) as presented in [Table 7].
Table 7: Multivariate logistic regression analysis of predictors of postnatal care utilization in Maiduguri

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  • Awareness of postnatal care (odds ratio [OR]: 12.04, 95% confidence interval [CI]: 10–26, P = 0.000)
  • Higher educational status of woman (OR: 7.15, 95% CI: 5–19, P = 0.000)
  • Having <5 children (low parity) (OR: 5.22, 95% CI: 3–21, P = 0.001)
  • Marital status (married woman) (OR: 3.44, 95% CI: 2–17, P = 0.002)
  • Husband's educational status (OR: 2.01, 95% CI: 1–13, P = 0.042).



  Discussion Top


It was observed that up to 69.4% of the participants did not attend antenatal care services and therefore had no opportunity to access health educative information from the service providers. This finding was very high when compared to a finding of 43% from a study in the southern part of the country and the 5% reported for the industrialized countries.[2],[12] However, the use of antenatal services in this study did not significantly influence the utilization of postnatal care services. This finding did not agree with the findings from some previous studies,[1],[4],[5] which documented significant relationship between attendance of antenatal services and utilization of postnatal services. The reason for the lack of correlation between antenatal attendance and utilization of postnatal services in our study was not well understood.

Although it is a governmental health policy to provide postnatal services to all women 6 weeks after delivery,[3] despite the efforts made to improve the quality of postnatal services in Nigeria, the use of postnatal care services in this study was found to be very low (16.9%); compared to 41.2%,[13] and the nearly 90% uptake of postnatal services reported in developed countries.[14] However, the 83.1% nonattendance at postnatal care in this study is extremely high compared with the nonattendance of 10.1% recorded in Zimbabwe.[14] The main reason for nonuse of postnatal care services in this study is the lack of awareness or not perceiving a need for it, which might be related to illiteracy as up to 41% of our respondents in this study had no any form of education. The study showed that most of the mothers (60.3%) were not knowledgeable about postnatal services. Among those who were aware (39.7%) of the services, quite a large proportion (29.5%) did not utilized the services; only 10.2% of them were aware and attended postnatal services. These results contrast with the findings of a study in Pakistan,[15] which found that out of the 26.2% of the mothers who knew about the postnatal services, 25% utilized them. Conversely, it is concerning to note that quite a large number of mothers 178 (53.6%) in this study, who did not attend postnatal services were not aware of the services. According to Omotara,[16] utilization of health care services in general is affected by awareness of the health care seekers. Studies have shown that women who had delivered at health facilities had more access to postnatal care,[2], 3, [12],[13],[14] as in the case of this study which revealed that majority (61.7%) of those who had the postnatal care had received prior antenatal care services and had delivered in a health facility. The low rate of awareness and utilization of postnatal care recorded in this study could possibly be due to many factors; apparent among which are the effect of traditional birth attendants, who according to the WHO,[5] they provide solution to many expectant mothers, including those who have got health problems in the postnatal period and these trends have had serious implications on awareness, access and acceptability of maternal and newborn health services. This study clearly showed that over 70% of the study population had delivered at home. Other factors are general insecurity of the study environment, and poor antenatal care attendance as recorded in this study.

Education of women is a positive factor for utilization of postnatal care services in this study after controlling for confounders, as it is in many other studies conducted in different parts of Africa.[2],[12],[13] The results from this study showed that educated women were 7 times more likely to have utilized postnatal care. The study found that women who had fewer children and had received antenatal care were 5 times more likely to have used postnatal care services. In this regards the results appear to be consistent with most studies done elsewhere, which indicate that women are significantly more likely to use delivery care services for their first child than later children [2],[3],[12],[13] Possible explanations for this are that women who are pregnant with their first child are usually happier, eager and the extreme joy they developed as a result of the pregnancy. They are also more likely to have difficulty during labor and delivery than women of high parity.

Although marriage is important and is also the norm in a society like Maiduguri, up to 7.2% of births in the present study occurred among women who were not married. Marital status is an important sociodemographic characteristic of an individual that affect the underlying tendency to seek health care in Africa.[2],[3],[12],[13] Interestingly married women were 3 times more likely to have received postnatal care services than the unmarried ones in this study.

The husband's education was also seen as an influential factor for utilization of postnatal care in our study. Women with husband's educated up to secondary school level and above were 2 times more likely to had postnatal care than those with primary and/or nonliterate husbands. Similar findings were reported by some studies.[12],[13],[17]

The external validity of this study is limited by the fact that the population was drawn from a single tertiary health facility and included only women of reproductive age group; therefore may not be generalized to the general population. In addition, the results might also be sensitive to other variables not studied or only inferred. The study did not collect information on service availability/accessibility in the rural parts of Maiduguri where majority resides, thus limiting the practical utility of the results, especially in the rural parts of the state where service factors are an important deterrent of use of maternity care. Despite these limitations, it is believed that the results have some potentially important implications. It is hoped that it will improve policymakers' understanding of the determinants of maternal and child mortality and morbidity in Borno state and serve as an important tool for any possible intervention aimed at improving the utilization of postnatal care services in the state and country at large.

 
  References Top

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Hove I, Siziya S, Katilo C, Tshimanga M. Prevalence and associated factors for non-utilization of postnatal care services: Population-based study in Kuwadzana peri-urban areas, Zyimba distric of West Province, 89 Zimbabwe. Afr J Reprod Health 1999;3:25-32.  Back to cited text no. 14
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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