History of Maternal Health Care Delivery System in Lagos State, Case Study Mushin Local Government Area

History of Maternal Health Care Delivery System in Lagos State, Case Study Mushin Local Government Area

CHAPTER ONE

AIM AND OBJECTIVES

AIM

To assess the History of maternal health care delivery system and its determinants at the Primary Health Care (PHC) level in Mushin Local Government Area, Lagos State.

SPECIFIC OBJECTIVES

1. To determine the proportion of women utilizing maternal health care services in the PHC centres in Mushin Local Government
2. To assess the adequacy of resources (human and material), and the level of continuity of maternal health care services in the PHC centres in Mushin Local Government Area.
3. To identify factors influencing the History of maternal health care delivery system in the PHC centres in Mushin Local Government

CHAPTER TWO

LITERATURE REVIEW

MATERNAL HEALTH CARE SERVICES

Maternal health care services comprise three elements: Community based services (Primary Health Care); Essential Obstetric Care at the first referral level to deal with complications and thirdly, effective communication and transport between the community-based services and the first referral centre. ²⁰

In a wider context of women’s reproductive health care, the following components of maternal health care services are recognized: Pre-conceptual (Premarital or Adolescent care); antenatal care; intrapartum care (Delivery services) and postpartum (Postnatal) care.¹⁹ The elements as enumerated above should have a linkage to these components as well as to family planning and specialist obstetric care at the tertiary level.

The antenatal period clearly presents opportunities for reaching pregnant women with a number of interventions that may be vital to the health and wellbeing of mothers and that of their infants. The basic objectives of antenatal care are to detect and manage symptomatic and even symptomless but potentially serious complications of pregnancy, and to meet the pregnant woman’s need for information, advice and reassurance.¹⁴ The antenatal care policy in Nigeria follows the newest WHO approach to promote safe pregnancies. It recommends at least four ANC visits for women who do not have obvious complications. This updated approach, called Focused Antenatal Care (FANC) emphasizes quality of care during each visit rather than focus on the number of visits. FANC hinges on the principle that every pregnancy is at risk of complications.¹⁴ Apart from receiving basic care, every pregnant woman should therefore be monitored for complications.¹⁴ This implies that for antenatal care to be effective, it should be goal directed, family centered, client oriented, evidence based, with reduced frequency of visits, however with emphasis on the quality of care by skilled providers.²¹

The content of FANC is an essential component of the quality of services. Activities and contents of a FANC include: Health education on proper nutrition, personal and environmental hygiene, danger signs of pregnancy and signs of labour; provision of preventive services, monitoring the progress of pregnancy; screening for early diagnosis; birth preparedness and complication readiness, and risk assessment to determine high risk pregnancy. Such medical examinations as measurement of blood pressure, urine testing for proteinuria, blood tests for anaemia and infections like syphilis and HIV/AIDS, have been proved to be beneficial. Cost effective interventions like the vaccination of women of reproductive age group with tetanus toxoid, prevention of mother to child transmission of HIV/AIDS (PMTCT), are affordable in most countries. However, some of these services are not accessible to most women who need them, probably because of reasons such as lack of awareness, cost, non-availability, rumours and fears of side effects, and the quality of services provided.

Nonetheless, it has become clear that antenatal care interventions alone cannot be expected to have the much desired significant impact on morbidity and mortality. It has been documented that the higher the proportion of deliveries attended by skilled birth attendants in a country, the lower the country’s maternal mortality ratio.²¹ Thus the safe motherhood programmes, and recently the Millennium Declaration base their priorities on the need for skilled care, including emergency obstetric care, rather than ensuring that all pregnant women received antenatal care.^16,23. In addition, conceptions are now changing from the once held belief that most life threatening obstetric complications are predictable and preventable. It has been revealed that large proportion of the so called “low risk” women develops complications. Therefore every pregnancy faces risks.²⁴ The United Nations Committee on Economic, Social and Cultural Rights (ESC Rights Committee) states that “health facilities, goods and services must be scientifically and medically appropriate and of good quality.” ²⁵ The ESC Right Committee concluded that in the absence of service capable of providing appropriate and effective care, carrying out of risk assessment is unethical. It therefore implies that quality maternal health care service requires inter alia, scientifically approved and unexpired drugs, hospital equipment, safe water, adequate sanitation and skilled medical personnel, including emergency obstetric care.

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CHAPTER THREE

RESEARCH METHODOLOGY

THE STUDY DESIGN

This was a cross – sectional descriptive study of the History of maternal health care delivery system rendered to women attending public PHC facilities in Mushin LGA.

THE STUDY POPULATION

This comprised of women utilizing maternal health care services in public PHC facilities in Mushin LGA during the period of the study, the health care workers providing maternal health care services at these facilities, the heads of these health facilities.

INCLUSION AND EXCLUSION CRITERIA FOR THE SELECTION OF HEALTH FACILITIES AND CLIENTS

INCLUSION CRITERIA

Women utilizing any of the maternal health services as enumerated below were selected. Only health facilities that provide at least three of the maternal health services viz: family planning, antenatal care, safe delivery services, postnatal care services and basic essential obstetric care, were selected for the study.

EXCLUSION CRITERIA

Women accessing other services at the facilities for non-maternal health services such as women who are very ill or need emergency treatment or treatment for other diseases and conditions were excluded. Women who declined to participate in the study were also excluded.

Health facilities that do not provide up to three of the services enumerated above were excluded from the study.

CHAPTER FOUR

RESULTS

All the health facilities had a CHO, two had staff nurse midwives (SNM), and one medical doctor covered all the primary health care facilities studied, while one had SCHEW, JCHEW and administrative officers. However, none of the health centers had a pharmacy technician, laboratory technologists, medical records officer and environmental health officers.

Table 15 summarizes the availability of essential drugs in the facilities studied. Most the drugs were available but in insufficient quantities except for ergometrine injection, gentian violet solution and oral rehydration salt. However, most of the facilities (75.0%) do not have procaine penicillin injection, fansidar tablets, tetracycline and chloramphenicol eye ointments.

Consumables

All the health care facilities assessed had consumables, which included needles and syringes, cotton wool, latex gloves, antiseptic lotion and sutures.

CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATION

Discussion

The findings of this study showed that the commonest maternal health care services sought for according to more than half of the respondents (60.0%) was antenatal care. Less than one- tenth (9.3%) of them utilized delivery services and 5.7% other services like family planning. The FGD also showed that majority of the clients come to these facilities mainly for ANC. This agrees with the findings of a study by Mandy in Kenya, where most facilities offered ANC but only 37% of them provided delivery care.⁵¹ This is also in conformity with the 2008 NDHS, which shows that in Lagos southeast Nigeria, 97.7 % of women received antenatal care services, 87.8% delivered in health facilities but only 26.1% deliveries occurred in public health facilities.¹⁴ When asked of the maternal health care services provided in the health facilities, the respondents at the FGD and KII sessions mentioned ANC, child welfare, delivery services, family planning services, counseling and postpartum care. These findings give an impression that a significant proportion of the clients comes for ANC but had their deliveries elsewhere.²⁹

The availability of services also is a prerequisite to its accessibility and utilization. The findings of this study showed that about one-third of clients did not receive tetanus toxoid vaccination and the main reason given for this was the non-availability of vaccines. This study also found out that none of the health facilities studied had the capacity to deliver even the full range of basic EOC. This agrees with the findings in a Nigerian study in 1998, the 2003 Nigerian NDHS and a study in Peru in 2006, that the met need for EOC is still low.^26–30 It also conforms with the finding of a 2003 study, where only 42% of public health facilities in Nigeria met internationally accepted standards for EOC.¹³ Essential obstetric care is one of the four pillars of safe motherhood, and has been identified as the main intervention strategy with the highest impact on maternal health.^40,106 It ensures that essential care for high risk pregnancies and complications is provided to all women who need it. Thus the WHO and UNICEF recommended one comprehensive and four basic EOC facilities for every 500,000 population.¹⁴ Perhaps, this low met need for EOC as has been reported by several studies is a major contributory factor to the unacceptably high maternal mortality rates in the country.

Laboratory services are important support services to maternal health care. Despite this, the findings of this study showed that none of the health facilities studied had a laboratory technologist. Also, essential laboratory facilities for obstetric care was lacking in three out of the four facilities. This would explain why some of the needed laboratory investigations were not carried out. This agrees with the finding in Zimbabwe; where poor quality of care provided by the health centre staff was attributed to limited availability of equipment coupled with poor know how by the available health personnel.⁵² Though less than half (44.8%) of the clients paid for laboratory services, FGD analysis showed that most of these investigations were done in laboratories outside these health facilities. This was said to be one of the causes of increased delay in seeking MHC services, particularly laboratory services. Also, the quality of the laboratory investigations done outside these facilities may be questionable except there is quality assurance assessment prior to using them. It then suffices that the type and quality of care provided to women often determine their survival through the processes of pregnancy, labour and puerperium.²⁹

Even where other resources are available and accessible, human resources were needed for proper management of these resources. The findings of this study showed that the health personnel were unevenly distributed and in all these facilities, the manpower was less than the minimum staff complement required.^{18, 105.} There was a shortage of medical officers and public health nurses, similar to the findings of other studies.^{18, 102, 105.} It was also revealed that there were no laboratory technologists nor pharmacy technicians in the entire PHC facilities run by the NNLG. Also only one medical doctor covered all the health facilities studied, while these facilities were manned by CHOs. Several studies have attributed maternal mortality ratio to such inadequacies as rudimentary or absent managerial skills shortage of staff, drugs, equipment and supplies.^{13, 98–100.}

Little wonder, none of the facilities is an EOC facility, as there were no personnel with the necessary skills needed to address the major causes of maternal mortality.^{8, 104.} This agrees with the finding that shortage of health professionals reduce the number of facilities equipped to offer EOC 24hrs a day and are significantly related to the quality of care and maternal mortality rates.¹⁰³ This finding was also in keeping with the Nigeria reproductive health resources and service survey, which reported paucity of skilled birth attendants and that this can affect the health workers capacity to offer effective and efficient MHC services.³⁰

Studies have shown that HMIS are often inadequate, inconsistent and at times non-existent. Every health facility is required to maintain records of its activities including MHC services. This study revealed a lot of deficiencies and inadequacies of the record system. None of the four health facilities studied had all the required HMIS forms. Where some of these forms were available, a lot of deficiencies were observed with regards to completeness and correctness of filling them. In addition, none of the health facilities had a record staff. Similar problems relating to record systems such as unavailability of required forms, lack of trained personnel, inconsistencies in record keeping, incompleteness and inaccuracies were also reported by some authors.^106,107.

Other key elements of the quality of service with respect to inadequacies include; the number of visits and the component of MHCs such as ANC services. From the findings of this study, most of the women 231 (83.1%) and 184 (66.26%) had their blood pressure and body weight respectively measured. Two hundred and eighteen (77.9%) received advice on drugs/ supplement, 196 (70.0%) had tetanus toxoid, 183 (65.3%) received health education on nutrition. Few, 115 (41.4%) had urine test for sugar and protein, 94 (33.8%) blood test for anaemia. These findings differed from the report of the study by Trinh et al, ¹¹⁰ where 9% of women reported receiving items on biomedical assessment, 8.6% in care provision/health promotion. However, more clinical assessments than laboratory tests were reported as was the case in another study.¹⁰⁹ This was said to be as a result of lack of equipment and skilled personnel in developing countries.

The finding that 196 (70.0%) had tetanus toxoid agreed with the report of the 2008 NDHS where 64% or more received two or more TT injections during pregnancy in the southern zones of the country where Mushin Local Government Area is.¹⁴ However, the 115 (41.4%) that had urine test was not in conformity with the 83.4% reported by the same 2008 NDHS.¹⁴ Nonetheless, variations occurred in the number that received supplements (89.8%), blood test for anaemia (89.9%), those that were weighed(88.4%) and BP(90.6%) as against 57.1%, 83.1%,66.2% and 83.1% respectively from this study. This may be because of lack of capacity to deliver such services

Continuity of care ensures that quality maternal health care services are available at all times. This implies that even conditions that cannot be handled at the PHC level can be referred to the next level with feedback to the peripheral staff who had made the referral. Lack of this continuity identified as a significant impediment to the provision of quality MHCs especially in emergency situations, and also is among factors that cause dissatisfaction among clients.^{92, 122.} Since the Primary Health Care (PHC) level is usually the first contact point for the majority of our women, it must be able to deliver the essential services in full and make appropriate referrals when necessary.

None of the centres studied had evidence in terms of printed referral forms or register to confirm referral, though they claimed referrals were done to secondary or tertiary institutions. Also none of the health facilities had transport facilities for referring women to the next level of care. Findings of the study showed that 37 (13.2%) of clients noted lack of means of transport for referral as one of the difficulties experienced in accessing care at the PHC facility. This finding was also similar to that of the FGDs, as no structures exist even at the community level for example transportation system or a community loan scheme, which have been found to reduce maternal mortality.⁸¹

The major reasons given by clients for avoiding referral were lack of transport. Other reasons given include: fear, lack of social and emotional support, unfamiliar environment, stigmatization and discrimination. These were similar to reasons given elsewhere for avoiding referral to other levels of health care delivery system.^{115, 116.}

CONCLUSIONS

This study concludes that the facilities available for the provision of maternal health services in Mushin LGA had most of the equipment, drugs and supplies available though they were inadequate.

Also the structures that house some of the facilities were not large enough to accommodate all the clients and providers. Water supply, power supply and refuse disposal system were not adequate. While factors reported to be responsible for difficulty in assessing services include: bad state of roads, high cost of transportation and payment before various services were received.

From this study, none of the health facilities had the capacity for even basic EOC. There were no laboratory technicians, no pharmacy technicians, only one of the facilities have a laboratory, while only one doctor covered the entire LG PHCs.

None of the facilities surveyed operated a Drug Revolving Fund scheme, nor had essential drugs list.

All the facilities received the available forms from the LGA health units regularly and on a monthly basis. However, the record system was found to be defective as there was no trained record officer in all the facilities studied. Some of the required forms were lacking and those available were incompletely and inaccurately filled.

Lack of vehicles designated for referral was also found as a factor that impeded the delivery of quality care.

The study found lack of comprehensive and integrated maternal health services, with ANC as the predominant service provided while others like delivery, PNC and family planning were underutilized.

This study showed that the disposition of the staff towards punctuality and interaction with clients was acceptable. This may have been the reason for the high level of satisfaction with the maternal health services by the clients despite the poor quality of services provided.

RECOMMENDATIONS

The following recommendations are made based on the findings from the study.

1. The NPHCDA as the main agency overseeing PHC should make available the list of all minimum resource requirements to all PHC departments nationwide and ensure strict compliance through regular inspection visits.
2. The Mushin Local Government should rehabilitate and ensure regular maintenance of the access roads to these
3. The LGA should ensure regular supply of HMIS forms. In addition, they should employ record officers, while monitoring and evaluation officers should ensure these forms are available, timely, completely and correctly
4. Laboratory facilities for the routine investigations should be made available in the LGA, and laboratory technicians employed.
5. The Mushin Local Government through the PHC Department should strengthen the capacity of the existing PHC facilities to provide at least basic EOC through the employment of more health personnel, training of existing ones and the provision of equipment, drugs, supplies and other necessary
6. Referral systems which should be supported by a reliable means of transportation should be established and strengthened by the LGA and the communities. Referral forms should also be made
7. Infrastructure – There should be provision of adequate potable water, power supply, refuse disposal system and renovation of facilities in the health The communities should liase with the government in this respect.
8. The health facilities in Mushin Local Government should ensure the delivery to the clients of comprehensive and integrated maternal health services

REFERENCES

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10. Donna V, Barbara Improving maternal health. e Journal USA: Economic perspectives, 2005; 1 – 7.
11. United Nations Population Population Report (Family Planning Programme). Improving quality services. Population Journal.1999; 47: 6 – 30.
12. Hodges A. ed: Children’s and women’s right in Nigeria, wake-up call: Situation assessment and analysis, Nigeria, Abuja. National Planning Commission and UNICEF; 2001; 2 – 10.
13. Fatusi A, Ijadunola K. National Study on essential obstetric care facilities in Abuja: Federal Ministry of Health and UNFPA: 2003.
14. National Population Commission (Nigeria) and ICF Macro Nigeria, Nigeria Demographic and Health Survey 2008. Calverton, Maryland: National Population Commission and ICF/Macro. 2009.
15. Sai Why should Africa’s woman continue crying for life? Second Annual Professor Olikoye Ransome Kuti International Policy Dialogue in Primary Health Care and Reproductive Health. Women’s Health and Action Research Centre publishers. Benin, 2007; 20-22

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