Content of antenatal care services in secondary health care facilities in Nigeria: implication for quality of maternal health care

OBJECTIVE: /st> To assess the contents of antenatal care and to relate the findings to the adequacy of maternal health care. DESIGN: /st> Cross-sectional study. SETTING: /st> Public secondary health-care facilities. PARTICIPANTS: /st> Pregnant women. INTERVENTIONS: /st> Three hundred and ninety consecutive pregnant women attending 12 selected secondary health facilities were recruited proportionate to the client load recorded for each facility during the year preceding the study. Interviews were conducted using the antenatal care exit interview form of the Safe Motherhood Needs Assessment package. MAIN OUTCOME MEASURES: /st> Antenatal care services provided to pregnant women in current pregnancy. RESULTS: /st> Blood pressure measurement, abdominal palpation and detection of foetal heart rate were provided to all participants. Three hundred and eighty-six (99%) were reached with at least one educational message. One hundred and sixty-seven (42.8%) had haemoglobin or packed cell volume estimated, whereas 168 (43.1%) had urine checked for protein, at least once during antenatal visits. Routine iron and folate supplements, and malaria prophylaxis were, respectively, given to 142 (36.4%) and 25 (6.4%). CONCLUSIONS: /st> The antenatal care service as provided had reasonable capacity for intervention against pre-eclampsia and some foetal problems, and could contribute to delivery in a health facility and by a health worker. Capacity to address the possible effects of severe anaemia and malaria in pregnancy was lacking. Equipping health-care facilities with capacity to detect anaemia and proteinuria as well as ensuring that iron and folate supplements, and malaria prophylaxis are given to all pregnant women would help to meet national guidelines and improve quality of service.     

Distance and the utilization of health facilities in rural Nigeria

The distance patients must travel in order to obtain treatment has long been recognized as a primary determinant of the utilization of health care facilities. The distance factor is especially significant in rural Third World settings where the density of Western-type health facilities is often low, where the majority of patients are likely to make the journey for treatment as pedestrians and where there are viable and usually more accessible alternate sources of medicine. This study examines the impact of distance on the utilization of health care facilities in the Hadejia area of Kano State, Nigeria. Per capita utilization was found to decline exponentially with distance. The rate of distance decay in utilization levels varies according to the type of facility, socio-demographic variables and illness. Hausa perceptions about sickness and about specific illnesses are reflected in the varying incidence of health facility utilization in the treatment of particular illnesses and distance decay gradients of varying steepness. Although the per capita consumption of health care decreases exponentially for concentric distance bands, individual villages show great disparities in utilization rates which are only partly attributable to distance.     

Inequalities in maternal health care utilization in rural Bangladesh

The article examines the inequalities in utilization of maternal health care in rural areas of Bangladesh. It also attempts to identify the expenditure pattern for these services. Findings suggest that large disparities in the maternal health care utilization exist between the poorest and the richest population in Bangladesh. Two in three women in the highest wealth group receive antenatal care from qualified doctors as opposed to one in five women in the lowest wealth group. Almost all the deliveries occur at home among the lowest wealth group, whereas 16% of deliveries occur at health facilities among the highest wealth group. Wealth is also associated with the seeking of care for delivery-related complications. The practice of seeking services during post-natal period is not common and it varies positively with economic condition. Family savings is found to be the dominant source of paying the maternal health care services among the women in the highest wealth group. Cost has been found to be the most commonly cited reason for not seeking care for delivery complications. Eighty-four percent of women in the lowest wealth group compared to 13% of women in the highest wealth group did not seek treatment for delivery complications due to cost. Lack of perceived need of antenatal care (ANC) and postnatal care is the most pressing reason for not seeking these services. The study findings contain a number of implications for policy purposes that could be useful in devising ways to increase the utilization of maternal health care services.     

The cost and efficiency of public and private health care facilities in Ogun state,Nigeria

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating at full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.     

The influence of health care on contraceptive acceptance in rural Mexico

This paper offers two types of evidence in support of the idea that family planning services are most expediently provided as an integral part of the health and medical organization for maternity care. First, prenatal care and medical attention at delivery are found to be closely associated with postpartum contraceptive acceptance in a 1981 survey of family planning in rural Mexico. Second, interviews of a sample of doctors, nurses, and auxiliaries who provide maternal health services to the rural population reveal that these practitioners favor long birth intervals and small completed families, that they recommend the use of modern contraceptive methods including female sterilization, and that those in the employ of public institutions are motivated to recruit acceptors of these methods. The main impediment to contraceptive acceptance in this context is believed to be fear of side effects and permanent health consequences rather than the desire for additional children.     

Barriers to the utilization of maternal health care in rural Mali

This study used data from the 2001 Demographic and Health Survey and multilevel logistic regression models to examine area- and individual-level barriers to the utilization of maternal health services in rural Mali. The analysis highlights a range of area-level influences on the use made of maternal health services. While the dearth of health facilities was a barrier to receipt of prenatal care in the first trimester, transportation barriers were more important for four or more prenatal visits, and distance barriers for delivery assistance by trained medical personnel and institutional delivery. Women's odds of utilizing maternal health services were strongly influenced by the practices of others in their areas of residence and by living in close proximity to people with secondary or higher education. Household poverty and personal problems were negatively related to all outcomes considered. The results highlight the importance of antenatal care and counseling about pregnancy complications for increasing the likelihood of appropriate delivery care, particularly among women living 15-29 km from a health facility. Area-level factors explained a greater proportion of the variation in delivery care than in prenatal care However, significant area variation in the utilization of maternal health services remained unexplained.     

The impact of stigma on maternal attitudes toward placement of children with disabilities in residential care facilities

This study examines willingness to consider placement of children with disabilities in residential care facilities among 81 mothers of children with disabilities. Perceived stigma is added to the Andersen and Newman model of health service utilization in order to evaluate its impact on placement attitudes controlling for predisposing, enabling and need characteristics and health beliefs. Findings of regression analyses suggest that older, single mothers of more severely disabled children are more likely than other mothers to consider residential placement and that adequate finances and residential stability may reduce this willingness. When these variables are controlled, the expectation that people with disabilities will be stigmatized by others in the community increases willingness to consider placement and does so by increasing the degree of caregiver burden experienced. Results also suggest, however, that among mothers of young children, specific aspects of perceived stigma have direct affects on willingness to consider placement even when perceived burden is controlled.     

Policy and practice: The case of medical facilities in Nigeria

Elaborate health programmes have always been an important feature of national development plans in Nigeria, especially since independence in 1960. The aspect of the programmes that is examined in this paper is the geographical distribution of medical facilities. The policy objectives in this regard have been to improve access to facilities and personnel by distributing them equatably according to population, and to correct the rural-urban imbalance in the system. But how far have these objectives been realized?In an attempt to answer this question, the situation in Bendel State is examined in some detail and the results show that the rural-urban imbalance is still evident. Correlation analyses showed that areas that have a comparatively large urban population have more facilities and personnel than areas that are predominantly rural. Also, three step-wise multiple regression analyses revealed that Urban population is a far more important factor than total population in explaining the distribution of hospitals, hospital beds and doctors.The doctor/population ratios are exceedingly high for the predominantly rural areas, over 1:70,000 in some cases. These ratios are far in excess of 1:14,000 which was the national target for 1980. All these show that some important policy objectives of the health programmes have not been realized.     

影响农村妇女孕产期保健的社会因素分析

目的:探讨影响农村妇女孕产期保健的社会因素。方法:采用定性研究方法,根据目的抽样的原则,抽取孕产期保健服务的提供者、利用者以及地方级别的关键知情人士进行焦点小组访谈、个人深入访谈和关键人物访谈。结果:家庭经济贫困的妇女相对经济好的妇女更不容易利用保健服务;新型农村合作医疗可以吸引妇女到医院分娩,提高住院分娩率,降低母婴死亡率;交通对孕产妇利用保健服务有很大的影响;计划生育政策是计划外生育妇女利用孕产期服务最主要的障碍;流动妇女对孕产期保健服务的利用率低;当地农村仍奉行一些关于生孩子的传统习俗。结论:建议政府制定相关政策限制日益增长的医疗费用;加强流动人口和计划外生育妇女的管理;对农村妇女进行孕产期健康教育;扩大新型农村合作医疗的覆盖范围。     

农村孕产期保健服务可及性的定性研究

目的:了解安徽省农村孕产期保健服务可及性,为制定干预方案及改善我国农村孕产期保健服务提供科学依据。方法:选取服务提供者及地方不同级别的关键知情人采用焦点小组访谈和个人深入访谈进行定性调查。结果:产前检查、住院分娩、产后访视和健康教育在乡镇卫生院都已开展,但是数量和质量达不到要求;计划生育部门协助开展了部分孕产期保健服务。近几年,服务提供者提高重视程度、加大经费投入、加强人员培训、加大宣传力度、改变行政管理,提高了孕产期保健服务的可及性。但是也存在资金投入不足、资金分配不平衡、"重临床轻保健"思想、健康教育不足、妇幼保健网络建设不完善、人力制约因素、私人门诊增加等问题,制约了孕产期保健的发展。结论:农村孕产期保健服务取得了一定的成绩,同时也存在着制约服务可及性的问题,应该采取因地制宜的措施,探索新的政府投入方式、乡镇和农村结合的孕产期保健模式,制定统一的孕产期保健服务规范等。     

Non-professional health practitioners and referrals to facilities: lessons from maternal care in Bangladesh

Over half a million women in the developing world die of pregnancy and childbirth related causes each year, despite well-known interventions to manage most maternal complications. One problem facing policy makers is that women in low-income settings often seek care from a range of non-professional sources when they have trouble with pregnancy and childbirth. Questions remain as to the best way to engage with such providers to encourage use of professional care, in part because little policy-oriented research has attempted to study the roles of non-professional practitioners, and the specific situations which can encourage or discourage referral behaviour. This paper investigates the roles played by alternative health practitioners in referral to facilities for maternal care in Bangladesh. In-depth case studies were used to investigate labour experiences, decision-making processes and the roles played by key individuals in deciding to use professional services. Findings show that the commonly used heading of 'traditional birth attendant' is often too broad for programmatic use, as it encompasses a range of individuals with different reasons to work with, or oppose, professional services. It was found that women seek care from multiple non-professional cadres who each have differing services, scopes and linkages to professional care. Policy makers need to understand the roles of different providers and potential links to professional care which can be built upon to encourage the use of professional emergency care for maternal complications in low-income settings.     

Expansion of rural health care and the use of maternal services in Nepal

In order to improve living standards among the rural poor, the government of Nepal has invested heavily in improving the provision of health care services in rural areas. The purpose of this paper is to assess the impact of this investment on the use of maternal health care services. A bivariate probit model is used to estimate the effect of physical access to government health care services, along with individual-, household-, and other location-specific characteristics, on the use of prenatal care and birth delivery care. The results of the estimation are used to carry out policy simulations that assess the magnitude of the impact of improvements in health care availability on service utilization. The results indicate that physical access to a health care facility, as it is currently structured in rural areas, has a statistically significant but modest impact on the use of maternal services.     

Methodology for optimising location of new primary health care facilities in rural communities: a case study in KwaZulu-Natal, South Africa

STUDY OBJECTIVE: To develop a quantitative methodology to optimally site new primary health care facilities so as to achieve the maximum population level increase in accessibility to care. The study aims to test the methodology in a rural community characterised by considerable heterogeneity in population distribution and health care access. DESIGN: A geographical information system was used to estimate travel time to the nearest primary health care facility for each of the 26 000 homesteads in the subdistrict. The homestead's travel time estimate was then converted into an impedance to care estimate using distance decay (in clinic use) data obtained from the subdistrict. A map of total person impedance/km(2) was then produced using a 3 km standard Gaussian filter. The resulting map was used to site a test clinic in the largest contiguous area of high person impedance. SETTING: Hlabisa health subdistrict, KwaZulu-Natal, South Africa. MAIN RESULTS: The population level increase in accessibility that would be achieved by the construction of the test clinic would be 3.6 times the increase in accessibility achieved by the construction of the newest clinic in the subdistrict. The corresponding ratio for increasing clinic coverage (% of the population within 60 minutes of care) would be 4.7. CONCLUSIONS: The methodology successfully identifies a locality for a new facility that would maximise the population level increase in accessibility to care. The same principles used in this research could also be applied in other settings. The methodology is of practical value in health research and practice and provides a framework for optimising location of new primary health care facilities.     

农村妇幼保健项目督导中发现的问题及思考

目的:阐述项目县农村妇幼保健项目督导工作中发现的问题并提出相应建议,推动项目的进展。方法:检查乡村两级相关资料的完整性,现场观察妇幼保健人员的工作,对乡村两级妇幼保健人员进行个人深入访谈。结果:培训对象希望培训内容更贴近其日常工作需要,希望进行实地学习;孕管册回收不全,资料填写不完整;妇幼保健人员报酬偏低和专职妇幼保健人员匮乏;村级妇幼保健工作质量得不到保证;计划外生育的妇女不注重产前检查及住院分娩;流动人口的妇幼保健服务利用率低;妇幼保健相关政策宣传不到位、受益面不广等。结论:各级相关机构应强调资料填写和收集工作的重要性,加强管理和督导;村计生管理员与村妇幼保健人员合二为一,给予村级妇幼保健人员经费支持;计划生育部门和卫生部门之间加强合作;加大健康教育和政策宣传的力度,不断充实宣教内容和改进宣教方法。