Increasing Women's Access to Skilled Pregnancy Care in Nigeria (IMCHA)

Child mortality under age five is regarded as an indicator of the progress of societal value systems in health care management (or lack thereof). The study showed significant urban-rural differentials in under-5 mortality rates across bio-demographic, socioeconomic and proximate factors. Strengthening maternal and child health (MCH) programmes specifically in rural areas, and improving health care services would help to ensure overall child survival. Disparities in access and utilization of health care services have hampered the target of promoting Universal Health Coverage (UHC), including widespread reduction in childhood mortalities.

The writer advances the notion that the incidence of “near misses” is a key indicator of quality of care, because it accounts for all components of emergency obstetric care in referral facilities. The article is in response to “Incidence, causes and correlates of maternal near-miss morbidity: a multi-centre cross-sectional study” [https://doi.org/10.1111/1471-0528.15578], which suggests that although women may experience delays in accessing referral facilities, concentrating efforts on complications through emergency obstetric care can be effective in preventing maternal deaths. As well, the respondent disputes the use of the study controls, arguing for ones that would better enable the identification of specific actions for prevention of maternal deaths.

Study findings show predictors of sub-optimal offerings of standard Primary Health Care (PHC) that include: local government area, marital status and previous childbirths. A higher proportion of maternal deaths in Nigeria occur among women living in rural areas, where barriers to maternal health include quality of care in health facilities. There is evidence of continuing under-utilization of primary care by pregnant women in poor and rural communities. Due to the small number of women who use PHC, and the non-availability of accurate records of women who use the facilities for maternal care, a sample size could not be determined beforehand.

Pregnant women in rural communities in Nigeria often do not use Primary Health Care Centres. Through focus group discussions, the study found four broad categories of reasons underlying non-use: 1) accessibility factors – poor roads and transportation, long distances, and facility not always open; 2) perceptions relating to poor quality of care, inadequate drugs, abusive care by health providers, long wait times, and inappropriate referrals; 3) costs of services, including inability to pay for services even when costs are not excessive; the introduction of informal payments by staff; and 4) partner support (or lack thereof), and misinterpretation of signs of pregnancy complications.

The study revealed factors associated with childhood mortality: age, region, residence, education, wealth index, age at first birth and religion of father and mother. Mothers living in rural areas experience a 28% increase in childhood mortality. Tackling the death of children, whether during perinatal, early or late neonatal, childhood or adolescent age is posing a difficult task in Nigeria. The study points to the correlation between improved health education campaigns and improvements in access to primary health care as directly effective in increasing life expectancy and economic wellbeing.