|Year : 2020 | Volume
| Issue : 1 | Page : 44-51
A comparative study on the availability of postnatal care services in primary health-care facilities in urban and rural settlements in Kaduna State, Nigeria
Chinedu John-Camillus Igboanusi1, Kabir Sabitu2, Awawu Grace Nmadu3, Istifanus Anekoson Joshua3, Abdulrazaq Abdullahi Gobir2
1 Department of Public Health, 2 Division Medical Services and Hospital, Headquarters 2 Division, Nigerian Army, Adekunle Fajuyi Cantonment, Ibadan, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
3 Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna, Nigeria
|Date of Submission||26-Feb-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||31-Jul-2020|
Dr. Chinedu John-Camillus Igboanusi
Department of Public Health, 2 Division Medical Services and Hospital, Headquarters 2 Division, Nigerian Army, Adekunle Fajuyi Cantonment, Ibadan
Source of Support: None, Conflict of Interest: None
Background: The days and weeks following childbirth is a critical phase in the lives of mothers and newborn babies. Major changes occur during this period which determine the well-being of mothers and newborns. Most maternal and infant deaths occur during this time. The study aimed at assessing and comparing the availability of postnatal care (PNC) services between primary health-care (PHC) facilities in urban and rural settlements in Kaduna State, Nigeria. Materials and Methods: This was a comparative mixed-method community-based study carried out in Sabon Gari and Giwa local government areas (LGAs) of Zaria. A multistage sampling technique was used to select 410 households in two LGAs. Structured questionnaires were used to collect data and the data were analyzed using the Statistical Package for the Social Sciences software version 20.0. Results: PNC services were available in the PHC facilities in the study areas, however, in varying degrees. The rural and urban PHCs had 25% and 64.3% of the recommended workforce, respectively. The recommended essential equipment availabilities for PHCs were 26.3% and 38.2% in rural and urban PHCs, respectively. The rural PHCs had 35.4% of the recommended essential drugs, while the urban PHCs had 72.5%. Quantitative findings tallied with focus group discussions that services were better in urban than in rural PHCs. Conclusion: PNC services were inadequate in both urban and rural areas of Kaduna State but more in the rural area. The PHC facilities studied lacked the recommended minimum requirements in terms of human resources for health, basic equipment, and essential drugs, and this was more marked in the rural facilities. The state PHC development agency needs to address shortages of workforce, equipment, and essential medicines in the study areas.
Keywords: Availability, comparative study, postnatal care, primary health-care cenetrs, rural and urban settlements
|How to cite this article:|
Igboanusi CJ, Sabitu K, Nmadu AG, Joshua IA, Gobir AA. A comparative study on the availability of postnatal care services in primary health-care facilities in urban and rural settlements in Kaduna State, Nigeria. Niger J Exp Clin Biosci 2020;8:44-51
|How to cite this URL:|
Igboanusi CJ, Sabitu K, Nmadu AG, Joshua IA, Gobir AA. A comparative study on the availability of postnatal care services in primary health-care facilities in urban and rural settlements in Kaduna State, Nigeria. Niger J Exp Clin Biosci [serial online] 2020 [cited 2021 Jan 21];8:44-51. Available from: https://www.njecbonline.org/text.asp?2020/8/1/44/291197
| Introduction|| |
The first 42 days following childbirth is a critical phase in the lives of mothers and newborn babies. The postnatal period according to the World Health Organization begins immediately after childbirth and lasts 6 weeks thereafter. A considerable number of changes take place during this period which affect the well-being of mothers and newborns alike. Lack of appropriate care during this period could lead to significant ill health and even death. About 830 women die from pregnancy or childbirth-related complications around the world every day, in addition, an estimated 303,000 women die from pregnancy and childbirth-related causes worldwide each year. Ninety-nine percentage of these mostly preventable deaths occur in developing countries.
Nigeria has the second highest burden of neonatal deaths in the world, with an estimated 9% of the total global neonatal deaths. Studies in developing countries have shown that most mothers and newborns do not receive the recommended postnatal check within 48 h after childbirth., Although the maternal mortality rate is high in Nigeria, there are considerable regional variations. The 2011 Multiple Indicator Cluster Survey and the 2013 Nigeria Demographic and Health Survey (NDHS) showed that the Northwest region had infant mortality rates of more than two times and one and half times higher than the Southwest region, respectively., Studies have also shown high perinatal mortality rates in Nigeria, with the Northwest region having far worse figures than national average values., The uptake of postnatal care (PNC) services is very low in Nigeria, more especially in the Northwest region. The current study aimed to assess and compare the availability of PNC services in primary health care (PHC) facilities in urban and rural settlements in Kaduna State, Nigeria. It is expected that the study will generate evidence-based information for decision-making for mounting interventions that would improve maternal and infant health outcomes in the studied communities. This study aimed at assessing and comparing the availability of PNC services between urban and rural PHC facilities in Kaduna State, Nigeria.
| Materials and Methods|| |
PHC facilities in two political wards each were studied in Giwa local government area (LGA) which is predominantly rural and Sabon Gari LGA which is predominantly urban. The projected populations of Sabon Gari and Giwa LGAs, in 2014, were 374,302 and 342,009, respectively (based on the 2006 census)., The two wards studied in Giwa LGA were Gangara and Dan Mahawayi communities, while those studied in Sabon Gari LGA were Jushi and Muchia communities. There is a general hospital in Giwa town, while the Ahmadu Bello University Teaching Hospital is located within the LGA. The predominant ethnic groups in both the study communities are the Hausa/Fulani who are mainly Muslims, while Igbo, Yoruba, Bajju, and others are in the minority.
This was a comparative, cross-sectional, and community-based study employing mixed qualitative and quantitative methods.
The study population included mothers within the postpartum period. All mothers with live births whose children survived beyond the first 42 days postpartum in the past 12 months before the study and newborn babies within 1 year of delivery were included in the study, while postpartum mothers who were seriously sick and newborns older than 1 year of age were excluded from the study. The selected PHC facilities in both Giwa and Sabon Gari LGAs were studied.
Sample size estimation
The estimated sample size was 410 per se gment of the study using the formula for estimating the minimum sample size for descriptive studies:
Where n = minimum required sample size.
2 = Design effect.
Zα is standard normal deviate corresponding to a level of significance (usually 5%) at 95% confidence interval = 1.96.
Zβ is standard deviate corresponding to a power of 1−β. The power of the test is set at 80% =0.84.
P1= Prevalence of PNC services utilization in an urban settlement from a previous study = 0.169.
P2= Prevalence of PNC services utilization in a rural settlement from a previous study = 0.29.
1 − p1= Proportion of mothers in the urban settlement who did not utilize PNC services.
1 − p2= Proportion of mothers in the rural settlement who did not utilize PNC services.
f = expected nonresponse rate, i.e., 10% of all the individuals enrolled in the study.
n = 408, hence 410 respondents were recruited in each study arm, thereby giving a total of 820 respondents in both arms of the study.
A multistage sampling technique was used to select the communities (political wards), health facilities, and households included in the study.
- Stage 1: The 23 LGAs in Kaduna State were stratified into predominantly urban and predominantly rural LGAs. Using simple random sampling technique by balloting, Sabon Gari LGA was selected from urban LGAs, while Giwa LGA was selected from the rural LGAs
- Stage 2: Two political wards out of eleven were randomly selected from Sabon Gari LGA (Jushi and Muchia) and Giwa LGA (Gangara and Dan Mahawayi). The PHCs in each of the four selected wards were used for the study
- Stage 3: All the households in the selected wards were numbered, and in each ward, 205 households were selected using a systematic sampling technique
- Stage 4: One eligible mother was selected per household for the study. In situ ations where there was more than one eligible respondent, simple random sampling by balloting was used to select one. Where there was no eligible respondent in a household, the researcher moved to the adjacent household.
A structured, interviewer-administered questionnaire adapted from the 2013 NDHS was used to capture information on sociodemographic characteristics of the respondents and the availability of PNC services in PHC facilities in the study areas. Checklists adapted from the medical teams international and the National Primary Health Care Development Agency (NPHCDA) Ward Minimum Health Care Package (WMHCP) in Nigeria were also used to gather relevant information on human resources for health (HRH) and essential equipment. The essential drugs were assessed using an adopted essential medicine list developed by the Kaduna State government. The questionnaires were administered using the Epi Info® digital mobile data collection method.
The percentage availability of HRH for each PHC was calculated using the formula:
In each PHC, the staff deficit was obtained by subtracting the number of staff available from the total number of core staff cadres recommended by the WMHCP of the NPHCDA of Nigeria. The core staff cadres included nurses/midwives, public health nurses, community health officers, Community Health Extension Workers (CHEW), and the Junior CHEW were used in the calculation.
The percentage equipment availability for each PHC was calculated using the formula:
A total number of pieces of equipment that are relevant to PNC services as recommended by the WMHCP of the NPHCDA were computed which was 1018. In each PHC, the equipment deficit was obtained by subtracting the quantity of equipment in stock from the number of equipment recommended by the WMHCP of the NPHCDA.
For the qualitative aspect of the study, a total of eight Focused Group Discussions (FGDs) were carried out, two in each of the selected wards. The FGD guide was adapted from previous studies., In each of the ward, two FGDs were carried out among eight purposefully selected participants. The FGDs were conducted in the Hausa language. The guide was translated into Hausa and the discussions were recorded with an audio recorder.
Data were analyzed using SPSS® version 20.0 software (IBM, SPSS Inc., Chicago, USA). Quantitative variables were summarized using appropriate measures of central tendency and dispersion. Categorical variables were presented as frequencies and percentages. Data were presented in tables and charts. Qualitative variables were analyzed thematically.
| Results|| |
A total number of 820 questionnaires were administered to the respondents in the two urban communities of Jushi and Muchia in Sabon Gari LGA and two rural communities of Gangara and Dan Mahawayi in Giwa LGA of Kaduna State. Two hundred and five questionnaires were administered in each community. The mean ages of the respondents were 27.0 ± 6.7 years and 25.5 ± 6.7 years in urban and rural settlements, respectively. The largest proportion of respondents fell within the age group of 20–24 years (26.3%) and 39.1% in both urban and rural communities, respectively. Majority of the respondents (98% and 99%) in urban and rural areas, respectively, were married. Muslims made up the majority of respondents accounting for over 87% of the total respondents in both the communities. About 20.2% of the respondents in the urban area and 37.1% of the respondents in the rural area had primary education. Most of the respondents were of Hausa/Fulani ethnicity and were multiparous [Table 1]. There were statistically significant differences in population composition concerning educational status, occupation, ethnicity, and parity of women between the two LGA (P ≤ 0.05) [Table 1].
|Table 1: Sociodemographic characteristics of respondents in Sabon Gari and Giwa local government areas of Kaduna State|
Click here to view
The availability of HRH in the urban area was 64.3%, while in the rural area, it was 25% [Table 2]. The availability of equipment in the urban area was 38.2%, while in the rural area, it was 26.3% [Table 3]. The average percentage of essential drugs relevant to PNC services that were available in Sabon Gari and Giwa LGAs was 72.5% and 35.4%, respectively [Figure 1].
|Table 2: Human resources for health availability in Jushi, Muchia, Gangara, and Dan Mahawayi primary health cares in Sabon Gari and Giwa local government areas of Kaduna State|
Click here to view
|Table 3: Equipment availability in Jushi, Muchia, Gangara, and Dan Mahawayi primary health cares in Sabon Gari and Giwa local government areas of Kaduna State|
Click here to view
|Figure 1: Availability essential drugs for postnatal care services in the study primary health cares|
Click here to view
Findings of focus group discussions conducted in the urban and rural areas
The findings showed that the majority of the participants in both urban and rural areas accessed PNC services in the respective health-care facilities; however, urban facilities were better equipped in terms of personnel, drugs, and equipment. Two participants in the rural area said, “We will like the government to send more doctors and nurses to us.” “We will like the government to put more facilities in our hospitals.” The rural participants opined that the health-care facilities were poorly equipped, and the government should endeavor to provide them with the basic equipment. A participant said that ”Government should employ more workers and buy more hospital equipment so that we don't waste so much time waiting for our turns to be attended to.” Another one said, ”We need more facilities in this hospital.” They perceived that the paucity of HRH was responsible for clinic days holding only once in a week and for why the PHC facilities do not provide 24-hours services. A participant said, ”The health care workers are hard working. They come to the clinic before our arrival. However, they can only attend to our postnatal check-up needs once a week and they don't even work till evening time.” The findings also showed that participants in the urban areas were able to get most of the prescribed drugs in their PHCs. However, the rural FGD participants complained that most of the prescribed drugs were out of stock in their health-care facilities.
| Discussion|| |
The study assessed and compared the availability of PNC services in PHC facilities in urban and rural settlements in Kaduna State. It was found that PNC services were available in the PHC facilities in both settlements of the study but to varying degrees. In terms of the recommended HRH, resources were more readily available in the urban area (64.3%) than in the rural area (25%). This was collaborated by qualitative findings where the participants, especially those in the rural areas, complained more of lack of adequate personnel as compared to those in the urban areas. This was similar to qualitative findings in a study conducted in rural Tanzania, which reported that the unavailability of qualified health workers at PHC facilities was a major reason for poor utilization. It has been reported that about one half of the global population lives in rural areas that are served by only 38% of the total nursing workforce and by less than a quarter of the total physicians' workforce. It has also been reported in both developed and developing nations that urban centers almost always have a remarkable higher concentration of physicians than in rural areas. This could be because most health professionals prefer to settle in urban centers that offer more opportunities for professional development as well as education and other amenities. This is collaborated by findings from Nicaragua where about half of the country's health personnel work in the capital city which contains only one-fifth of the country's population. Similarly, a study conducted in Bangladesh reported that about 35% of doctors and 30% of nurses were located in four metropolitan areas where only 14.5% of the population lived. This concentration pattern is typical of third world countries.
To adjust this geographical disequilibrium in the distribution of HRH, governments have used carrot-and-stick measures (a combination of reward and punishment) in the form of mandatory service and incentives. As it turns out, rural/urban disequilibrium of HRH has proved to be a difficult problem to solve worldwide. However, some countries have achieved some measure of success in policies and programs designed to address this imbalance. For example, Thailand has successfully started reducing the rural to urban migration of health-care workers and from the public to private facilities with a wide range of monetary inducements.
The current study revealed inadequate equipment relevant to the provision of PNC services in both the study areas. The urban PHCs had only 38.2% of the recommended equipment as compared to 26.3% of their rural counterparts. Respondents from rural PHCs confirmed in FGD that their PHCs were poorly equipped. This was in congruence with the findings of studies conducted in Nnewi, Nigeria, where it was observed that there were a dearth of drugs and sundries, equipment, and skilled personnel among others in the health facilities studied., Studies conducted in Tanzania, South African and rural parts of America have similarly reported about shortages of medical equipment in health facilities.,, These deficiencies were higher in the rural than urban health facilities just as reported in some other countries.,,
The characteristics of an effective health system should, among others, include its ability to possess necessary medical equipment irrespective of their geographical location, which can have direct impacts on health-care services delivery and health outcomes. In a study carried out in rural Tanzania, it was reported that deficiencies in the availability of medical equipment negatively impacted on indices of maternal and neonatal mortality. In a South African study, the unavailability of equipment, low quality, and poor maintenance of available few negatively impacted on health outcomes. Some studies in other countries have similarly shown more shortages of equipment in rural hospitals than in urban hospitals in just as was reflected in this study.,, Availability of sufficient and well-functioning medical equipment has been a challenge to low-income countries with limited resources like Nigeria.
This study showed that the availability of essential medicines was far better in urban areas than in rural areas. These were collaborated by FGDs finding in which participants from urban areas said that they were able to get most of the prescribed drugs in the pharmacies of the PHCs. However, rural FGD participants complained that most of the prescribed drugs were out of stock in their health-care facilities. A qualitative study in rural Tanzania similarly reported that basic drugs were not available in the health facilities, making the patients to source for drugs from elsewhere. Data available from 27 developing countries reported an average public sector essential drug availability of 34.9% in rural settlements. Another survey of health facilities in Myanmar, South-East Asia, similarly found high availability of medicines for communicable diseases in public facilities at all levels of care in township areas, but lower availability of medicines for NCDs, especially at the rural primary care level. This could be attributed to factors such as high population density, better income opportunities in urban areas and the relative sophistication of the urban populace in relation to the rural populace. Thus, encouraging the concentration of health facilities and supplies in the urban areas to the detriment of rural areas.
The current study showed better availability of health personnel, equipment, and essential drugs in urban in comparison to rural PHCs. A study conducted in rural Tanzania similarly reflected these finding with rural facilities featuring unavailability of drugs and poor workforce situations cumulating to poor service delivery.
| Conclusion|| |
This study revealed a large disparity in the availability of PNC services between the urban and rural areas. Although both urban and rural facilities did not have sufficient resources, it was more evident in the rural areas. Deficiencies spanned across inadequacy of HRH, essential equipment, and essential medicines in both study communities.
In light of the findings of the study, it is recommended that the state government takes urgent steps to address the deficiencies in human resources in the PHC centers, especially in the rural areas. There is a need for deploying more personnel to these facilities and providing incentives to ensure their retention. Medical equipment should be provided for the PHC facilities in the state both in the rural and urban areas to enhance service delivery. Essential drugs should be procured and deployed by the responsible state agency to health facilities, especially those located in the rural areas. These interventions would enhance the availability and uptake of PNC services both in the rural and urban areas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liabsuetrakul T, Oumudee N. Effect of health insurance on delivery care utilisation and perceived delays and barriers among Southern Thai women. BMC Public Health 2011;11:510.
WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Maternal Mortality Estimation Inter-Agency Group. Maternal Mortality in 1990-2015. Unites States of America, Geneva: WHO; 2015. Available from: http://www.who.int/gho/maternal_health/countries/usa.pdf?ua=1
. [Last accessed on 2017 Feb 02].
Tanzania Ministry of Health, National Bureau of Statistics, ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015–2016. Tanzania Ministry of Health: Dar es Salaam, Tanzania; 2016.
Bwalya BB, Mulenga MC, Mulenga JN. Factors associated with postnatal care for newborns in Zambia: Analysis of the 2013-14 Zambia demographic and health survey. BMC Pregnancy Childbirth 2017;17:418.
National Population Commission (NPC) [Nigeria] and ICF International. 2014. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International; 2013.
Fawole AO, Shah A, Tongo O, Dara K, El-Ladan AM, Umezulike AC, et al
. Determinants of perinatal mortality in Nigeria. Int J Gynaecol Obstet 2011;114:37-42.
Dahiru T, Aliyu AA. Stillbirth in Nigeria: Rates and risk factors based on the 2013 Nigeria DHS. Open Access Library J 2016;3:1-2.
Somefun OD, Ibisomi L. Determinants of postnatal care non-utilization among women in Nigeria. BMC Res Notes 2016;9:21.
Giwa Local Government Area. Official Health Data and Records. Primary Health Care Department, Giwa Local Government Council. Kaduna State, Nigeria; June, 2015.
Sabon Gari Local Government Area. Official Health Data and Records. Primary Health Care Department, Sabon Gari Local Government Council, Sabon Gari, Kaduna State, Nigeria; June, 2015.
Takai IU, Dlakwa HD, Bukar M, Audu BM, Kwayabura AS, Takai IU, et al
. Factors responsible for under-utilization of postnatal care services in Maiduguri, North-Eastern Nigeria. Sahel Med J 2015;18:109-15. [Full text]
Bhattacherjee S, Datta S, Saha JB, Chakraborty M, Bhattacherjee S, Datta S, et al
. Maternal health care services utilization in tea gardens of Darjeeling, India. J Basic Clin Reprod Sci 2013;2:1-9.
Medical Teams International. Maternal and Newborn Care Health Facility Checklist; 2016. Available from: https://images.template.net
. [Last accessed on 2017 Jan 06].
National Primary Health Care Development Agency. Ward Minimum Health Care Package in Nigeria. Abuja; 2007.
Kaduna State, Nigeria. Essential Drug List for Primary Health Centres; 2014.
Chi PC, Bulage P, Urdal H, Sundby J. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy Childbirth 2015;15:18.
Titaley CR, Hunter CL, Heywood P, Dibley MJ. Why don't some women attend antenatal and postnatal care services?: A qualitative study of community members' perspectives in Garut, Sukabumi and Ciamis districts of West Java Province, Indonesia. BMC Pregnancy Childbirth 2010;10:61.
Kahabuka C, Kvåle G, Moland KM, Hinderaker SG. Why caretakers bypass Primary Health Care facilities for child care – A case from rural Tanzania. BMC Health Serv Res 2011;11:315.
Blumenthal DS. Geographic imbalances of physician supply: An international comparison. J Rural Health 1994;10:109-18.
Nigenda G, Machado MH. From state to market: The Nicaraguan labour market for health personnel. Health Policy Plan 2000;15:312-8.
Hossain B, Begum K. Survey of the existing health workforce of Ministry of Health Bangladesh. Hum Resour Health Dev J 1998;29:109-16.
Wilbulpolprasert S. Inequitable distribution of doctors: Can it be solved? Hum Resour Health Dev J 1999;3:2-22.
Health System Trust. National Health Care Facilities Baseline Audit: Summary Report, Health System Trust. Durban, South Africa; 2012.
McQuoid-Mason DJ. Public health officials and MECs should be held liable for harm caused to patients through incompetence, indifference, maladministration or negligence regarding the availability of hospital equipment. S Afr Med J 2016;106:681-3.
American Hospital Association. Opportunities and Challenges for Rural Hospitals in an Era of Health Reform. Washington, DC: Avalere; 2011.
Essendi H, Johnson FA, Madise N, Matthews Z, Falkingham J, Bahaj AS, et al
. Infrastructural challenges to better health in maternity facilities in rural Kenya: Community and health worker perceptions. Reprod Health 2015;9:103.
Eygelaar JE, Stellenberg EL. Barriers to quality patient care in rural district hospitals. Curationis 2012;35:36.
Sleeth J, Bach P, Summers A. Health systems resources and resource constraints. Queens University: Global Health Education Consortium; 2012.
Moyimane MB, Matlala SF, Kekana MP. Experiences of nurses on the critical shortage of medical equipment at a rural district hospital in South Africa: A qualitative study. Pan Afr Med J 2017;28:100.
Penfold S, Shamba D, Hanson C, Jaribu J, Manzi F, Marchant T, et al
. Staff experiences of providing maternity services in rural southern Tanzania – A focus on equipment, drug and supply issues. BMC Health Serv Res 2013;13:61.
Adhikari R. Effect of Women's autonomy on maternal health service utilization in Nepal: A cross sectional study. BMC Womens Health 2016;16:26.
World Health Organization. Improving Access to Medicines in the South-East Asia Region: Progress, Challenges, Priorities. Regional Office for South-East Asia: World Health Organization; 2017.
[Table 1], [Table 2], [Table 3]