|Year : 2020 | Volume
| Issue : 2 | Page : 88-93
Delays in accessing antenatal care services in a developing nation tertiary health center
Natalia Adamou1, Saeed Okatewun Abdul2, Usman Aliyu Umar1
1 Department of Obstetrics and Gynaecology, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||15-Mar-2019|
|Date of Acceptance||25-Jun-2019|
|Date of Web Publication||10-Jul-2020|
Dr. Usman Aliyu Umar
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, PMB 3452, Kano
Background: Delay in seeking medical care is common and constitutes a major unresolved public health problem. It could contribute immensely to maternal mortality, especially in developing countries, where access and availability of functional health-care facility have remained a challenge. Objective: This study aimed at identifying the forms of delays encountered by pregnant women seeking antenatal care (ANC) services and also factors responsible for such delays. Materials and Methods: This was a cross-sectional study among women attending antenatal care clinic of our hospital. Data were obtained through an interviewer-administered questionnaire and were analyzed by the Statistical Package for the Social Sciences version 17. Results: The mean age of the respondents was 28.6 (standard deviation [SD] ± 5.44) years. About a third (31.5%) experienced Type II delays due to inaccessibility to the mode of transportation and traffic deadlock; while majority (77.1%) experienced intrahospital delays due to delay in retrieving cases notes, seeing an obstetrician, inadequate health personnel, and consulting rooms. The average waiting time was 3.1 ± 0.91 SD hours (188 min). The waiting time was not statistically associated with time of arrival to the clinic. Conclusion: Most women experience intrahospital delays while seeking ANC. Intervention by policymakers and adequate staffing coupled with provision of necessary health-care amenities will go a long way in reducing patients waiting time.
Keywords: Antenatal care, delays, Kano
|How to cite this article:|
Adamou N, Abdul SO, Umar UA. Delays in accessing antenatal care services in a developing nation tertiary health center. Sahel Med J 2020;23:88-93
|How to cite this URL:|
Adamou N, Abdul SO, Umar UA. Delays in accessing antenatal care services in a developing nation tertiary health center. Sahel Med J [serial online] 2020 [cited 2021 Jun 18];23:88-93. Available from: https://www.smjonline.org/text.asp?2020/23/2/88/289345
| Introduction|| |
Antenatal care is a specialized pattern of care organized for the pregnant women to enable them attain and maintain a state of good health throughout pregnancy to improve their chances of having a safe delivery of a healthy infant at term. The major objective of antenatal care is to ensure optimal health outcomes for the mother and her baby.,, It entails series of consultations and follow-up offered by a specialized health worker (doctors, midwives, and trained auxiliary nurse) with the aim of monitoring pregnancy and fetal growth, early detection of complications and prompt treatment, and prevention of diseases through immunization and micronutrient supplementation., It also ensures birth preparedness and complication readiness and general health promotion through health messages and counseling for pregnant women.,,
The World Health Organization (WHO) introduced different antenatal care models over 15 years to improve maternal and child outcome. The traditional form which involves a series of visits every 4 weeks until 28 weeks and then fortnightly till 36 weeks and every week until delivery was challenging in resource-constricted countries. In 2001, focused antenatal care model was introduced, involves fewer (four) visits, and focuses on the quality of care and not quantity., Four visits were recommended for developing countries due to financial challenges. However, less frequent visits did not solve the problem in reduction in perinatal and maternal mortality, pregnancy complications, and led to less satisfaction with the reduced visit. New WHO guidelines recommend eight visits instead of four during the pregnancy, which provides greater opportunity to meet health provider, to increase chances in diagnosing complications, to implement preventive measures, and to improve communication between pregnant woman and her medical practitioner. It recommends visits as the first contact in the first 12 weeks and subsequently at 20, 26, 30, 34, 36, 38, and 40 weeks' gestation.,
Globally, 86% of pregnant women access antenatal care with skilled health personnel at least once with only three in five (62%) receiving at least four antenatal visits.
In regions with the highest rates of maternal mortality, such as sub-Saharan Africa and South Asia, even fewer women receive at least four antenatal visits (52% and 46%, respectively).
The 2013 Nigeria demographic health survey showed that only about 61% of women received antenatal care services from trained personnel.
There is an inverse relationship between antenatal care utilization and maternal mortality ratio (MMR) with nations having a higher antenatal care uptake having much lower MMR compared with those with low antenatal care (ANC) coverage.,, Factors limiting utilization of antenatal care services range from maternal educational status, age, financial status, cultural differences, accessibility to health-care facility, and delays in receiving health-care services even within health facilities.,,,,
“Three delays” model was introduced since 1991 to describe obstetric obstacles that contribute to maternal mortality. Type I delay is delay in the decision to seek care due to the financial implications, poor understanding of risks, and complications. Type II delay is due to delay in reaching care as a result of location, distance, and transportation. Type III delay includes delay in receiving adequate health care due to lack of medical facilities, inadequately trained staff, or inadequate referral. Socioeconomic and cultural factors, accessibility of facilities, and quality of care may independently affect the lengths of these three delays.
Affordability of quality antenatal care is a problem in the most government hospital. These coupled with long distance, poor road network, and long waiting hours in the hospital in addition to the attitude of the health caregiver may also limit the utilization of ANC services.,, Waiting time in hospital before accessing health is another contributing factor. Although there is no agreed standardize waiting time, the Institute of Medicine (IOM) recommends that at least 90% of patients should be seen within 30 min of their scheduled appointment time.,
The objective of this study is to identify challenges faced by women attending antenatal care clinic in our teaching hospital, especially delays faced within the hospital.
| Materials and Methods|| |
The study was a cross sectional study conducted over a period of 4 days from March 5 to 8, 2018. This corresponds to the antenatal clinic days of the various teams in the obstetrics and gynecology department of the hospital.
Patients were recruited by convenient sampling technique. A focused group interview was also done between health care providers related to ANC services (two health record officers, two nurses in the antenatal clinic, and four doctors one in each of the four teams that run the antenatal clinic) with a view of finding out reasons for intra-hospital delay in accessing ANC services.
For this study, booked patients were taken as those who had had at least two antenatal visits after the booking visit. Distance from clients' home and our hospital was classified as near, if it is <5 km, far, if between 5 and 35 km, and very far, if more than 35 km.
Information were extracted through an interviewer administered questionnaire, and data obtained were analyzed by the Statistical Package for the Social Sciences (SPSS) version 17 (SPSS Inc., Chicago, IL, USA). Chi square tests were used to compare differences between categorical variables. P ≤ 5% (0.05) for consideration of statistical significance.
Ethical clearance was obtained for the study from the Research and Ethics Committee, Aminu Kano Teaching Hospital, Kano, Nigeria. Date of approval is 12th February 2018. All procedures were in accordance of the 2013 Geneva declaration guideline.
Only booked patients who were willing to participate were recruited. All participants were fully counseled about the study, and an informed consent was obtained.
| Results|| |
A total of 100 questionnaires were made available but 92 clients responded, giving a response rate of 92%. The ages of the respondents ranged from 18 to 45 years with the mean age being 28.6 (standard deviation [SD] ± 5.44) years. All 92 respondents were married and 72 (78.3%) were of Hausa/Fulani ethnicity while majority 88 (95.7%) lived in urban dwellings. Most of the respondents 82 (89.1%) were Muslims. Furthermore, 46 (50%) of the respondents had tertiary education while 2 (2.2%) were not educated. This is shown in [Table 1].
Gravidity ranged from 1 to 9 pregnancies with mean gravidity of 3 (SD ± 2) pregnancies out of whom 13 (16%) were grand multiparas.
Most of the respondents 84 (91.3%) had adequate knowledge on the meaning of antenatal care and 86 (93.5%) believed that ANC was required by every pregnant woman. Most clients 62 (67.4%) believed that ANC should be commenced between 4 and 6 months gestation with 77 (83.6%) booking their index pregnancy between 16 and 24 weeks of pregnancy. Mean gestational age at booking was 19.6 (SD ± 4.32) weeks. Majority of patients reside far from Aminu Kano Teaching Hospital, Kano, Nigeria. Seventy-three clients (79.3%) come to the clinic by car, 17 (18.5%) through tricycles, while 2 (2.2%) of the respondents who lived near Aminu Kano Teaching Hospital trekked. Details are shown in [Table 2]. [Table 3] shows that most of the respondents 63 (68.5) do not experience any form of Type II delay; however, 29 (31.5%) respondents had various forms of Type II delays almost all of which were due to getting vehicle (taxi) or traffic deadlock. Majority 51 (55.4%) of the respondents arrived before 8:00 am (about a third arrive before 7:00 am) while 41 (44.6%) arrive by 8:00 am and beyond. Despite early arrival, only 27 (29.3%) clients had their case files retrieved within 30 min of arrival, while 26 (28.3%) had their case files retrieved after 1 h. Most 71 (77.1%) of the respondents have to wait for 3 h or more before seeing a doctor. Only 21 (22.9%) were seen within 1–2 h of arrival. The mean waiting time was found to be 3.14 (SD ± 0.91) h (188 ± 55 min).
Concerning attitude of the health workers, 82 (89.1%) felt that the health workers had a kind attitude during interactions with patients. Most of the patients 58 (63%) wished to be seeing by the attending doctor within 30 min of arrival. In all, 79 (85.9%) clients rated our antenatal services as satisfactory. This is shown in [Table 4].
Clients living near the hospital, those with four or less parity and those who were unemployed, were more likely to arrive the antenatal clinic earlier compared to clients who reside far distance from our hospital or those who were working-class women or of higher (5 or more) parity. However, this was not of statistical significance. Furthermore, people who arrived before 8:00 am are likely to see an obstetrician within 2 h when compared to those who arrive after 8:00 am. The differences were found not to be statistically significant (χ2 = 1.269; df = 1; P = 0.260). Details are shown in [Table 5].
| Discussion|| |
The mean age of respondents was 28 (SD ± 5.44) years which is within the recommended age for childbearing. However, 8 (8.7%) of the respondents were aged 35 years and above. Most of the clients were Muslims living in urban areas and were of Hausa-Fulani ethnicity. This may be attributed to the study location (Kano) where the major ethnic groups are Hausa.
Knowledge on the meaning and need for ANC were found to be high (91.3% and 93.5%), respectively. These may be attributed to the relatively high literacy rate found in this study as 90 (97.8%) had at least primary education.
Mean gestational age at booking found was 19.6 (SD ± 4.32) weeks. This was similar to that found in Benue (19.1 ± 7.8) and slightly less than that found in Ado Ekiti 21.1 (SD ± 6.98 weeks).,
About one-third of the clients experienced type II delays which result from delay in accessing vehicle for transport to the hospital and delays due to traffic congestion. This is similar to studies earlier highlighted where delay in accessing transportation was identified as reasons for delays in accessing health-care services.,,,
Delays noticed in retrieving patients' case notes were found to be due to misfiling, inadequate health record staffs, and absence of a computerize filling system in Aminu Kano Teaching Hospital, Kano, Nigeria. There was no statistically significant relationship (P > 0.05) between the time of arrival and the waiting period. Patients that presented earlier to the clinic were seen first.
Patients' parity, employment status, and distance of the place of resident also contributed to the time of arrival to the antenatal clinic, but this was also not of statistical significance. This was in keeping with reasons noted for delays in accessing health care from studies highlighted above.,,,,, More so, these factors may possibly be confounded by distance from the hospital.
The average waiting time was 3.1 (SD ± 0.91) h (188 min). This was much longer than that (30 min) recommended by the IOM; however, this was lower to that found in Benin (228 min) but higher than Ibadan (133 min)., Other factors identified for this delay in addition to the delay in retrieving patients' case notes were inadequate number of obstetricians and consulting rooms. Furthermore, the doctors arrive at the antenatal clinic at 10:00 am every day after a daily academic meeting, whereas most patients arrive before 8:00 am thus necessitating prolong waiting time.
| Conclusion|| |
Majority of the respondent experiences intrahospital delays before accessing health-care services. Major reasons noted for these delays include lack of adequate health-care personnel, insufficient consulting rooms, and lack of modern health record facility. Intervention by policymakers and adequate staffing coupled with the provision of necessary amenities will go a long way in reducing patients waiting time.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Omigbodun AO. Precoception and antenatal care. In: Kwawukume EY, Ekele BA, Danso KA, Emuveyan EE, editors. Comprehensive Obstetrics in the Tropics. 2nd
ed.. Accra-North: Assemble of God literature Ltd.; 2015. p. 18-23.
Fagbamigbe AF, Idemudia ES. Barriers to antenatal care use in Nigeria: Evidences from non-users and implications for maternal health programming. BMC Pregnancy Childbirth 2015;15:95.
Adhikari T, Sahu D, Nair S, Saha KB, Sharma RK, Pandey A. Factors associated with utilization of antenatal care services among tribal women: A study of selected states. Indian J Med Res 2016;144:58-66.
] [Full text]
Ojong IN, Uga AL, Chiotu CN. Knowledge and attitude of pregnant women towards focused ante natal care services in University of Calabar teaching hospital, Calabar, cross river state, Nigeria. Int J Nurs Midwife Health Relat Cases 2015;1:14-23.
World Health Organization. WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. Geneva: World Health Organization; 2002.
Mchenga M, Burger R, von Fintel D. Examining the impact of WHO's focused antenatal care policy on early access, underutilisation and quality of antenatal care services in Malawi: A retrospective study. BMC Health Serv Res 2019;19:295.
Doctor HV, Bairagi R, Findley SE, Helleringer S. Northern Nigeria maternal, newborn and child health programme: Selected analyses from population-based baseline survey. Open Demogr J 2011;4:11-21.
Ashir GM, Doctor HV, Afenyadu GY. Performance based financing and uptake of maternal and child health services in Yobe sate, Northern Nigeria. Glob J Health Sci 2013;5:34-41.
Dairo M, Owoyokun KE. Factors affecting the utilization of antenatal care services in Ibadan, Nigeria. Benin J Postgrad Med 2010;12:1-6.
Onasoga O, Joel A, Bukola DO. Factors influencing utilization of antenatal care services among pregnant women in Ife central local government area, Osun state Nigeria. Pelagia Res Lib Adv Appl Sci Res 2012;3:1309-15.
MacDonald T, Jackson S, Charles MC, Periel M, Jean-Baptiste MV, Salomon A, et al.
The fourth delay and community-driven solutions to reduce maternal mortality in rural Haiti: A community-based action research study. BMC Pregnancy Childbirth 2018;18:254.
O'Malley MS, Fletcher SW, Fletcher RH, Earp JA. Measuring patient waiting time in a practice setting: A comparison of methods. J Ambul Care Manage 1983;6:20-7.
Oche M, Adamu H. Determinants of patient waiting time in the general outpatient department of a tertiary health institution in North Western Nigeria. Ann Med Health Sci Res 2013;3:588-92.
] [Full text]
Federal Republic of Nigeria. Provisional results of the main findings of 2006 census. Government notice No. 3, B52, Lagos, Federal Republic of Nigeria. Official Gazette 2007;94:589-91.
Ifenne DI, Utoo BT. Gestational age at booking for antenatal care in a tertiary health facility in North-central, Nigeria. Niger Med J 2012;53:236-9.
] [Full text]
Aduloju OP, Akintayo AA, Ade-Ojo IP, Awoleke JO, Aduloju T, Ogundare OR. Gestational age at initiation of antenatal care in a tertiary hospital, Southwestern Nigeria. Niger J Clin Pract 2016;19:772-7.
] [Full text]
Kawungezi PC, AkiiBua D, Aleni C, Chitayi M, Niwaha A, Kazibwe A, et al.
Attendance and utilization of antenatal care (ANC) services: Multi-center study in upcountry areas of Uganda. Open J Prev Med 2015;5:132-42.
Nwaeze IL, Enabor OO, Oluwasola TA, Aimakhu CO. Perception and satisfaction with quality of antenatal care services among pregnant women at the university college hospital, Ibadan, Nigeria. Ann Ib Postgrad Med 2013;11:22-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]