Background: Access to antenatal and delivery and post natal services in Benue state Nigeria is less than recommended by the World Health Organization. The objective of the study was to determine the proportion of women who attended Ante Natal Care (ANC) and whose deliveries were attended to by skilled birth attendants as well as factors associated with utilization of skilled delivery services among women attending under five clinics in Makurdi Benue state.

Methods: The study was a cross sectional study including 300 mothers of infants aged less than six months. An interviewer administered structured questionnaire was used to obtain socio demographic data and information on ANC and attendants at last delivery. Data was analyzed using SPSS version 20. Chi-square tests were used to determine associations between outcome and exposure variables.

Results: Among the respondents, 94.3% had antenatal care during their last pregnancy, 88% had their delivery at a health facility while 94% were attended to by a skilled birth attendant. About three quarters of the respondents reside within a 30 minutes travel time to the nearest health facility. Higher level education and ANC attendance were significantly associated with health facility delivery.

Conclusions: The level of utilization of antenatal care and health facility delivery is higher than findings from many previous studies in resource constrained settings. Higher level of educational attainment and attending ANC were significantly associated with having delivery attended to by a skilled birth attendant. There is need to intensify the health education programme to achieve universal access to skilled delivery

• Skilled birth attendant
• Delivery
• Antenatal
• Makurdi

Bako IA, Ukpabi ED, Egwuda L (2017) Utilization of Antenatal and Delivery Services: A Cross Sectional Survey of Mothers in Makurdi, Benue State, Nigeria. J Family Med Community Health 4(2): 1104.

The burden of maternal mortality has remained high in many developing countries including Nigeria. The Maternal Mortality Ratio for Nigeria was estimated to be 576 deaths per 100,000 live births [1]. Access to antenatal care and skilled delivery services are key to reducing this burden in developing countries [2]. This has become even more imperative because about half of maternal deaths occur in Sub Saharan Africa. The major direct causes of maternal mortality in developing countries include conditions such as post-partum hemorrhage, puerperal sepsis, pre-eclampsia and eclampsia, obstructed labour and abortion, most of which are preventable if access to health care is increased [3-5].

Maternal health services are important indicators of the quality of health care in any country and utilization of these services correlate with maternal and child health outcomes [6,7]. According to World Health Organization (WHO), maternal health services include care that women receive during pregnancy, childbirth, and the postpartum period in order to reduce maternal morbidity and mortality [8]. The importance of reducing maternal mortality necessitated the inclusion of maternal health in the Millennium Development Goals with the aim of reducing maternal mortality by 75% between 1990 and 2015 [9]. The WHO recommends that all deliveries be attended to by a skilled birth attendant (SBA).

Even though maternal health services are relatively cheap and available in most parts of the world, its utilization in developing countries has been a major concern, making the achievement of the global target of access to skilled delivery of 80% by 2010 and 90% by 2015 a significant challenge in many developing countries, including Nigeria. While skilled attendance has reached 99.5% in many developed countries and more than 71 per cent of births globally, it is less common in developing countries such as Africa (46.5%) and Asia (65.4%) [9].

Even within Africa, skilled birth attendant rates variy widely from 79 % in Ga East Municipality of Ghana [10], to 40.3% in Makueni, Kenya [11], and to 13% in Goya and Tundunya political wards of Katsina state, Nigeria [1].Recent surveys in Nigeria have shown that only one-third of births take place in health facilities, with the lowest being in North West Zone (12%) and highest in the South East Zone (78%) [1]. There are also disparities between urban and rural populations, with rural areas suffering worse outcomes [12,13]. Traditional birth attendants (TBAs) assisted in taking deliveries in 13.5% of the pregnancies in Sagamu South West Nigeria and 4. 8% in Kaduna South, Nigeria [14,15].

Several factors have been found to hinder access to antenatal and delivery services in Nigeria. Availability of skilled manpower, drugs and equipment are important factors. Other factors such as distance to health facilities, economic, socio-cultural factors, quality of health care, including staff attitude, have also been found to be important determinants of access to antenatal and delivery services [16-20].

Not much is known about local factors associated with utilization of ANC and delivery services in Makurdi, Benue State. It is therefore important to have a clearer understanding of the pattern of ANC attendance and delivery in Makurdi Benue State to enable policy makers and health practitioners device means of improving access to skilled attendance at delivery. The objective of the study was to determine the proportion of pregnant women who attended ANC and births attended to by skilled birth attendants as well as factors associated with utilization of skilled delivery services among mothers of children attending under five clinics in Makurdi Benue state.

Study Setting

This study was carried out in Makurdi, the state capital of Benue State in North Central Nigeria. It lies between latitude 7.730 and 8.320. It has a population of about 300,377 people [21]. The majority of the population are farmers. The major ethnic groups are the Tiv, Idoma and Igede. As of 2007, Makurdi had an estimated population of 500,797 [21]. The study was conducted in three major child welfare Clinics in Makurdi metropolis: 1) Well child clinic of the Benue State University Teaching Hospital, 2) Makurdi, Child Welfare Clinic of the State Epidemiology Unit, Makurdi and 3) the Child Welfare Clinic of the Family Support Clinic, Makurdi. These clinics were set up and mandated to monitor the growth of children under-five, administer routine immunization, health education including demonstrations and attend to minor ailments of children under-five years.

Study Design

An analytical cross sectional study was used to determine the utilization of antenatal and delivery services and associated factors among mothers of children attending under five clinics in Makurdi, Benue state, Nigeria.

Study Population

The study was conducted among mothers of children aged 0-6 months, visiting under-five clinics in Makurdi, Benue state comprising Benue state University teaching hospital, Epidemiological unit and FSP clinic. The inclusion criteria included being resident in Makurdi or environs and having an infant aged between 0 and 6 months of age at the time of the study and attending fewer than five clinics in the selected health facilities.

Sample Size Estimation

The minimum sample size was calculated using the formula:

Where:

n is the minimum sample size,

At 95% confidence level and 5% precision:

P= Proportion who delivered in a health facility from a previous study, 24.0% [23].

Z = 1.96, P = 0.115, d = 0.025

N = 

The sample size was increased to 300 to account for possible non response or incompleteness of the questionnaires.

Sampling technique

A multi-stage sampling technique was applied. There are four major Child Welfare Clinics in Makurdi. Three under-five clinics in Makurdi were selected by simple Random sampling. The clinics selected were the Family Support Clinic, State Epidemiology Unit, and the State Teaching Hospital. The women who brought their infants (0-6 moths) to the Child Welfare Clinics within the period of the study in these facilities and consented to participate in the survey were selected consecutively until the sample size was obtained.

Data Collection

An interviewer administered, semi-structured and pre-tested questionnaire was used to collect data with assistance of trained research assistants (Medical Students). The questionnaire obtained information on the mother’s socio-demographic variables and maternal health care services utilization. Data collection was done on clinic days between Mondays and Fridays. The research assistants had prior short training on interviewing skills, methodology of the study and ethical issues.

Data Analysis

The filled questionnaires were examined for completeness and entered into spreadsheet and then exported to Statistical Package for Social Sciences (SPSS) version 20 for further cleaning and analysis. The main outcome variable was the use of a ‘skilled health assistant’ at delivery. A skilled health assistant is defined as a Doctor and/or nurse/midwives at delivery, while Traditional birth attendant (TBA), relatives and others were considered as unskilled assistants. The exposure variables included age, educational attainment, employment status, number of previous deliveries, utilization of ANC services and distance to the nearest health facility to place of residence of respondent. Chi square testing was used to test for associations between the outcome and the exposure variables.

Ethical Consideration

Ethical approval for the study was obtained from the ethical review committee of Benue State University Teaching Hospital, Makurdi. Signed informed consent of the mothers was obtained after explaining the aims and objectives of the study and what their participation entails. In order to guarantee anonymity of each participant, the names of respondents, addresses and identification information will be excluded.

Results

A total of 300 women were studied, majority of which were aged 20-29 (215, 71.6%) years, had secondary education (165, 55.0%), were Christians (291, 97%) and Tiv by tribe (199, 66.3%). Close to a third (31.7%) were traders while 23% were housewives. Respondents were mostly married (295, 98.3%) and a majority have had 2-3 deliveries (142, 47.3%), (Table 1).

Table 1: Socio Demographic Characteristics of respondents.

Three quarter of the respondents (75.7%) reside within 30 minutes travel time to the nearest health facility. Most of the respondents attended antenatal clinic during their last pregnancy (75.7%) having had at least 4 visits. The majority of respondents (264, 88%) delivered in a health facility while 94% had their deliveries attended to by a skilled birth attendant (Table 2).

Table 2: Access to ANC and delivery services.

Traditional birth attendant attended to 3.3% of the deliveries while other non-skilled persons attended to 2.7% (Figure i).

Figure 1:

Almost ninety percent and 86.5% of respondents aged 25 years and above and those 24 years and below had their last delivery at health facility respectively. The relationship between place of delivery and age group was not statistically significant (P=0.448). About three quarter of respondents with primary education or lower had their deliveries in a health facility compared to 84.6% among those with secondary education or higher (P=00.5). Respondents who had ANC were more likely to deliver in a health facility (89.4%) when compared to those who didn’t attend ANC (64.7), P=002. Those who made 4 or more visits were more likely to deliver in the health facility (92.1%) when compared to those who had 1-3 visits (78.6%), P<0.001) (Table 3,4).

Table 3: Selected characteristics and ANC Attendance.

Table 4: Selected characteristics and place of last delivery.

Discussion

This study found that out of a total of 300 women, the majority were aged 20-29 years, married (98.3%) and 47.3% have had 2-3 deliveries. Majority of the respondents attended ANC during their last pregnancy (94.3%) while about 75% had four or more visits and 5.7% having no ANC at all. The Nigeria NDHS 2013 reported that 74.5% of urban residents had four or more ANC visits in their last pregnancy and 10.9% had no ANC. A number of factors were found to affect health facility delivery [1]. Our study found that older age (25 years and above), higher education and parity of four or more were associated with having four or more ANC visits in the last pregnancy.

A majority of the respondents (88%) delivered in a health facility while 94% had their deliveries attended to by a skilled birth attendant. This rate is high when compared with findings from previous studies. The NDHS in 2013 showed that in Benue state, 50.9% of deliveries took place in the health facility, compared to an average of 45.7% for North central Nigeria and 35.8% for Nigeria. Most developing countries have an average of 46.5% of deliveries attended to by skilled personnel [9].In Ghana, Makueni in Kenya and Goya/Tundunya wards in Katsina, Nigeria, 79%, 40.3% and 13 % of pregnant women delivered in a health facility respectively [10,11]. However in developed countries, almost all deliveries are attended to by a skilled birth attendant [9]. This relatively high level of health facility delivery could be attributed to the urban setting where the study was conducted and the fact that the study was facility based. It could also be due to increased awareness on the importance of ANC and delivery in the health facilities as a result of interventions form NGOs and government agencies.

Traditional birth attendants attended to 3.3% of the deliveries while other non-skilled persons attended to 2.7%. The national average of proportion of pregnant women who had their deliveries attended to by TBA was 13.4% in 2014 [1].

Higher educational attainment was significantly associated with delivery at the health facility, which is consistent with previous studies in plateau state and in Makueni County, Kenya [24,25]. However in Nepal, respondents who had secondary and above were less likely to deliver in the health facility when compared with those with lower education while in an urban PHC in Ibadan, educational level did not significantly affect utilization of the facility [26,27]. Higher number of ANC visits were significantly associated with delivery at the health facility. This finding is similar to the finding of NDHS 2013 which showed that health facility delivery was 4.3%, 28.3% and 60.6% respectively for pregnant women who had no ANC, 1-3 ANC visits and four or more visits [1]. This finding also agrees with other previous studies which showed that delivery at the health facility was significantly associated with ANC attendance [24-25].

Close to a quarter of the mothers take more than 30 minutes to reach the nearest health facility, but this did not significantly affect ANC attendance and delivery at the health facility. This finding is contrary to the widely held recognition of the importance of travel time to the health facility in determining utilization of health care facilities. In Ga Municipality of Ghana, the time it takes to reach the health facility was significantly associated with health facility delivery [10]. Distance to health care centers was similarly cited as a reason for not delivering in the health facility by 36.4% of women in Russia village,Jos Plateau state and by 68.5% of respondents in Kaduna South [24,26]. Longer travel time in accessing a health facility is due mainly to longer distance, poor road networks and lack of transportation facilities. However, our study was conducted in the urban setting where most of these challenges are not as prevalent.

It is possible that some women do not bring their babies to the health facilities and therefore were missed in this study.

This group of women is likely to have a delivery pattern that is significantly different from those who attend immunization clinics. The NDHS 2013 report shows that in Benue state, Nigeria, the proportion of babies immunized with OPV2 and measles were 41.8% and 42.7% respectively, implying that a significant proportion of women don’t bring their babies to the clinic for immunization [1]. It is however worthy of note that in Nigeria, most urban babies of residents are immunized.

Antenatal care attendance during the respondents’ last pregnancy was 94.3% while 88% had their delivery at a health facility. Respondents who had their last deliveries attended to by TBA and other non-skilled workers were 3.3% and 2.7% respectively. About three quarter of the respondents reside within a 30 minutes travel time to the nearest health facility. Higher level education and ANC attendance were significantly associated with health facility delivery.

The level of utilization of antenatal care and health facility delivery is higher than findings from many previous studies in resource constraint settings. There is need to intensify health education programs to achieve a universal access to skilled delivery. Similar studies should be conducted in the rural areas of Benue State.

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