Importance of provision and utilization of MCH services

CHAPTER TWO

Review of Related Literature

This chapter presents the review of related literature on the extent of provision and utilization of free MCHS among the childbearing mothers in Igbo-Eze North LGA of Enugu State. Literature on the subject abound. A few of them are from Nigeria while a great number of them are conducted elsewhere in foreign countries. The review of related literature is organized under the following headings:

Conceptual Framework

·     Concept of maternal and child health services (MCHS)

·     Provision and Utilization of health services.

·     Measurement of extent of provision and utilization of MCHS

·     Demographic factors associated with the extent of utilization of free MCHS.

Theoretical Framework

·        Theory of health seeking-behaviour.

·        Theory of attachment.

Empirical Studies on Extent of Provision and Utilization of Free MCH Services

Summary of Literature Review

Conceptual Framework

This section will review the concepts of MCHS, and extent of provision and utilization of MCHS. Numerous researchers have defined MCHS diversely. However, most of them have common conceptual focus.

Concept of maternal and child health services.

Maternal and child health services (MCHS) are those health services provided for childbearing mothers and their children to protect them from sickness, trauma and death. Department of Education and Early Childhood-DEEC (2013) defined Maternal and Child Health Service as a universal primary care service for families with children from birth to school age. The targets for MCHS are all women in their reproductive age groups, i.e., 15 - 49 years of age, children, school age population and adolescents (Addisse, 2003). Oklahoma State Department of Health-OSDH, (2013) added that MCHS’s mission is to provide state leadership, in partnership with key stake holders, to improve the physical and mental health, safety and well-being of the mother and child population. The service provides a comprehensive and focused approach for the promotion, prevention, early detection, and intervention of the physical, emotional or social factors affecting the health of young children and their families in contemporary communities (DEEC, 2013).

MCHS is aimed at helping to improve the health of mothers and their newborns in order to reduce maternal and child morbidity and mortality. This may be only possible if the services are accessible to mothers and children in terms of financial cost. This may be why the Department of Health and Human Services-DHHS (2010) described MCHS as a broad array of programmes organized to improve the availability of and access to high quality preventive and primary health care for all children and to reproductive health care for all woman and their partners regardless of their ability to pay. In the present study, MCH services  are those health services given to mothers and their children regardless of their ability to pay for the services in order to reduce the rate of maternal and child death and achieve the optimal health for both the mother and her child. Programmes under MCHS may include maternal health and child health.

Maternal health services (MHS) are all the health care services a mother receives during pregnancy, childbirth and after child birth. Onuzulike (2004) defined MHS as health or health-related care fashioned towards helping mother to cope successfully with physical or psychological strains under which they are exposed to in the course of fulfilling their roles as wives and mothers. Mothers need assistance in their childbearing period because they face with a lot of challenges in this period. Federal Ministry of Health-FMOH (2007) identified that during pregnancy and childbirth, mothers are always challenged by conditions such as haemorrhage, puerperal, sepsis, obstructed labour, unsafe abortion and pregnancy-induced hypertension. Others are malaria, HIV and AIDs,  diabetes  mellitus and  hepatitis.  This makes the mothers a vulnerable

group. In the context of this study, MHS means health services for the mother during pregnancy, childbirth and 6 months after delivery. Maternal health services may include prenatal care, antenatal care, delivery care, and postpartum care. Others are family planning, emergency obstetric care, and post-abortion care.

Pre-conception cares are health actions directed toward preparing a mother for a safe and a risky-free pregnancy and child-bearing. PATHS (2005), and Ara and Islam (2013) described pre-conception care as the information and services (such as screening for and managing conditions which may complicate pregnancy, childbirth and health of the mother and child) given to an individual or couple who intend to biologically father or mother a child. According to Holt (2008), pre-conception counseling may include assessment of lifestyle such as diet, exercise, consumption of alcohol or tobacco, and ways of dealing with stress; recommendation of vitamins; administration of necessary vaccinations; and general advice about maintaining healthy habits. Koblinsky and Corberff (1987) observed that the risk of maternal death is up to 15 times higher for women who do not receive pre-natal care than it is for those who do. However, when a woman eventually gets pregnant, she needs antenatal care for her welfare and that of her unborn child.

Antenatal care is the care of the women during pregnancy. Park (2014) defined antenatal care as the care which mothers receive from healthcare professionals during their pregnancies. The above report further noted that the purpose of antenatal care is to monitor mothers’ health, the babies’ health and support families to make child-bearing plans which are right for them. During pregnancy, it is very important that mother takes good care of her own health and that of her baby. This includes taking good nutrition at appropriate quantity and quality. According to UNFPA (2014), the primary objective of antenatal care is to establish contact with the women, and identify and manage current

and potential risks and problems. UNFPA (2014) maintained that this creates the opportunity for the woman and her health care provider to establish a delivery plan based on her unique needs, resources and circumstances. Therefore, the delivery plan identifies her intentions about where and with whom she intends to give birth and contingency plans in the event of complications (transport, place of referral, etc). With this, a mother may be guaranteed a safe-delivery.

Safe-delivery is a procedure of assisting women who undergo rigorous labour processes and peurperium without injury, infection or any form of morbidity (PATHS, 2005). If pregnant women are handled effectively during labour, the factors that lead to maternal mortality and morbidity may be drastically reduced. After delivery, a mother still needs a postpartum care.

A woman, in the course of childbirth may undergo enormous physiological and emotional stress. She needs to be cared for after delivery so that she may fully recover from the pains accompanying childbirth. This care is known as postpartum care. Adama (2008) defined postpartum care as the care given to mothers after delivery to recuperate from injuries associated with childbirth. This seems to reverse the physiological changes that occurred during pregnancy and delivery, and to restore the body to its pre-pregnancy state. During this period, breastfeeding is established, and family planning is introduced to avert early occurrence of another pregnancy (Lucas & Gilles, 2003).

Family planning involves the management of number and space of births. Derek (1993) described family planning as a means of helping individuals and couples choose the number of children they will have. He added that the choice depends on a complicated mixture of social, cultural and psychological influences. PATHS (2005) defined family planning as a way of thinking and living adopted voluntarily upon the basis of knowledge, attitudes and responsible decisions by individual and couples in order to promote the health of family and thus contribute effectively to the social development of the country. Another care for the mother worth discussing is abortion and post-abortion care.

Abortion means termination of pregnancy before the end of its term. It is the death or expulsion of the foetus either spontaneously or by induction before the 28^th week of the pregnancy (Myles, 2009). According to Umar (1993), abortion involves the detachment, forcing out or expulsion of the incompletely developed foetus or embryo from the mother’s womb before viability. Abortion always comes with complications making post-abortion care very necessary.

Post-abortion care means after-abortion care. This means care given to a woman following abortion. NPSM (2003) described post-abortion as offering contraception to a woman who has experienced an abortion complication as a way of preventing subsequent abortion. The above report recommended the need for administration of broad spectrum antibiotics intravenous fluids, and blood transfusion to prevent, infection, de-hydration and anaemia that may lead to maternal morbidity or mortality. In addition to the foregoing, mothers need obstetric and other maternal cares.

Emergency obstetric care and Life saving skills are cares given to a woman to ensure that risks of complications associated with pregnancy and delivery are prevented. Emergency obstetric care and Life saving skills are targeted towards saving the life and promoting the health of the mother and her child in the course of and after delivery (PATHS, 2005). UNFPA (2014) advised that since up to 50 per cent of maternal deaths occur after delivery, a midwife or a trained and supervised Traditional Birth Attendant (TBA) should visit all mothers as soon as possible within the first 24-48 hours after birth. Ara and Islam (2013) advised that the midwife or TBA should assess the mother's general condition and recovery after childbirth and identify any special needs. A child also needs health services.

Child health services (CHS) are services directed towards ensuring that a child is totally healthy. WHO (2000) defined CHS as an aspect of modern services specifically designed for health promotion, disease prevention, and treatment of children under five years of age. According to Park (2009), CHS is that branch of medical science that deals with the care of children from conception to childhood, in health and disease. According to Bennette (2004), CHS comprises immunization services, promotion of breastfeeding, oral rehydration therapy, nutrition education, antennal and postnatal treatment of minor prevalent illnesses as well as outreach programmes. In the present study, CHS refers to an aspect of modern services specifically designed for health promotion, disease prevention, and treatment of children under five years of age. AlHilfy and Esaa (2007) had aptly noted that mothers and children are vulnerable groups that need special care through maternal care; for women in the child-bearing period, especially the pregnant and lactating, and through child care; for children below five years infants and preschool children. If all these programmes are fully pursued, the rates of morbidity and mortality may be reduced to the barest minimum among the under 5 and childbearing mothers.

A childbearing mother is one in her reproductive age (i.e. between puberty and menopause). She may be described as that woman who has the natural capability to conceive and give birth, and who may be between the ages of 12 to 49 or above. Child-bearing age has been described as the period in a woman’s life between puberty and menopause (Williams & Wilkins, 2006). Experts, as reported by Medical News Today-MNT (2005), advised that the best age for childbearing remains 20-35.  MNT (2005) warned that age-related fertility problems increase after 35 and dramatically after 40. Under-aged mothers may also be at the high risk of pregnancy-related complication. WHO (2012) reported that young adolescents face a higher risk of complications and death as a result of pregnancy than older women. Studies like Jatau (2000), and Williams and Wilkins (2006) showed that adolescent pregnancy is an exploding problem in Sub-Saharan Africa. Young women under 20 years of age in Africa are more likely to have a child than those in other regions (Daly, Azefor & Nasah, 1993). For example, by age 18 more than 40 percent of the women in Africa have given birth already (Senderwitz 1993). In clarifying this, Daly, Azefor and Nasah (1993) reported that in Africa, 1 in 5 adolescent women will have a birth in a given year. They noted that most of the births to teenagers are first births and women having their first child carry higher risk of serious medical complications. The above report further reveals that babies who are first births face a higher infant mortality rate than higher order births and this risk is even greater for teenage mothers. However, a childbearing mother (also interchangeably used with women of childbearing age) in this study is a woman who is in a period between her puberty and menopause, and who still give birth to a child. If necessary cares are not made available and accessible to childbearing mothers, there may be increase in the rate of maternal morbidity.

Maternal morbidity is a pregnancy related health problems or disabilities which women suffer during or after childbirth, but not result into death (NPSM, 2003). Price (2002) reported that an estimated 40 per cent and above of pregnant women, which equivalent to 50 million women experience pregnancy related health problems during or after childbirth each year. The report further indicated that 15 per cent of these women suffer severe or long-term, often dilapidating complications such as uterine prolapsed (sliding of the uterus from its normal position), fistulae (hole in the vagina), pelvic inflammatory disease (PID), and infertility. These complications if not well managed may lead to maternal mortality.

Maternal mortality is the number of deaths of childbearing mothers in a year due to pregnancy or childbirth. Maternal mortality is the annual number of women who die from pregnancy- or childbirth-related complications per 100,000 live births (Indexmundi, 2013). According to Addisse (2003) maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the site and duration of pregnancy from any acutely related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

The rate of maternal mortality is found to be associated with lifetime risk of mothers among other factors. The joint report of  WHO, UNICEF, UNFPA and the World Bank (2012) described lifetime risk as the probability that a woman will die from complications of pregnancy and childbirth over her lifetime; it takes into account both the maternal mortality ratio and the total fertility rate (probable number of births per woman during her reproductive years). Thus in a high-fertility setting a woman faces the risk of maternal death multiple times, and her lifetime risk of death will be higher than in a low-fertility setting. The lifetime risk of maternal death in the developing world in 2010 as a whole was 1 in 150, compared with industrialized regions with an estimated 1 in 4,700. Among the regions, women in sub-Saharan Africa face the highest lifetime risk –  one maternal death in every 39 births. However, maternal death or illness appears to affect her children and entire household. According to Canadian Institute for Health Information-CIHI (2001), a woman's death during childbirth may lead to the death of the child. This is known as child mortality.

Child mortality is the annual number of deaths of children below the age of 5 years per 100,000 live births (Indexmundi, 2013). Maternal and infant death may be prevented by ensuring that maternal health complications are recognized, referred, and treated by skilled health care and that women and children access high quality MCHS. However, for MCHS to achieve its aim depends on the extent of its provision.

Extent of provision implies the degree of supply or availability of something. The word ‘extent’ is synonymous to ‘degree’. According to Farlex (2013), ‘extent’ means the range, magnitude, or distance over which a thing extends. Babylon (2014) described ‘extent’ as how much; how many; or what degree. The word “extent’ in this study means how much. Also in the present study, it is used as extent of provision.

Provision means supply or availability of something. Farlex (2014) defined provision in three distinct ways thus: i) the act of supplying or fitting out: ii) something provided: and iii) a stock of necessary supplies. According to Vocabulary.com (2013), a provision is a store or supply of something like food or clothing. The above definitions agree that provision is making something available. In this study, provision means the supply of health facilities necessary for MCHS. This study will concentrate on the extent of provision of MCHS. However, extent of provision of MCHS may influence its utilization.

Utilization means making use of something or finding a practical or effective use for something. Farlex (2013) described it as an act of using something. This work is interested in service utilization. According to Hampton and Nagy (2013), service utilization refers to the extent to which people are making use of whatever services which are already available in the community or at one’s organization. RobDavies (2013) described utilization mathematically thus: it is the ratio of time a system is busy (i.e. working for us), divided by the time it is available. For example, if MCH services is available for 160 hours and busy for 40 hours only, then utilization is 40/160= 0.25. So, there is 25 per cent of utilization. In this study, utilization refers to the extent at which childbearing mothers and their children are making use of MCH services which are available in the community. Adequate provision and utilization of MCHS remain the proven tools for curbing the rates of mortality and morbidity among women of child bearing age and their children. Extent of provision and utilization of MCH services are measurable.

Measurement of extent of provision and utilization of MCH services.

Measurement refers to the assignment of numerals to objects or events according to rules (Nwachukwu, 2007). Nwachukwu noted that measurement is conducted using instruments like a range, a scale or a test. Any instrument capable of providing dependable measurement must possess certain qualities such as validity, reliability and usability (Nwachukwu, 2007).

Provision and utilization may be regarded as practices. Practice according to Hornby (2005) simply mean action. Therefore, provision and utilization can be regarded as practice because both involve action. In this study, methods applied in measuring practice will be applied in the measurement of extent of provision and utilization of MCH services.

In measuring the extent of provision of MCH services, the rating scale of “a large extent (LE)”, “some extent (SE)” and “Never (N)” according Gemson (2011) can be

applied. “YES” and “NO” option according to Enyi (2006) can be used to measure practice (provision and utilization). Sometimes, question with multiple option where the respondent is expected to choose an option can be used to measure practice. In this study, the three options above will be employed to ascertain the extent of provision and utilization of MCH services.

Importance of provision and utilization of MCH services.

Increasing the proportion of mothers who are cared for in health facilities during pregnancy, childbirth and puerperium reduces the health risks and deaths of mothers and their children. In MCH services, emphasis is placed on ensuring services to childbearing women, infants, children, and adolescents (including children with special health care needs, low income populations, those with poor nutritional status and those who do not have access to health care) (UNICEF, 2013). This is the main function of MCH services where provided. The importance of MCH services is not limited to the health of mothers and children or their immediate problems. Rather, it shows the role and necessity of MCH services in the welfare of the family, the community and the country as a whole. Thus, MCH is an issue that has to be addressed in terms of national productivity and futurity of a country.

UNICEF (2013) clamours the need for provision of MCH services given that every single day, Nigeria loses about 2,300 under-five year olds and 145 women of childbearing age. This makes the country the second largest contributor to the under–five and maternal mortality rate in the world.

Preventable or treatable infectious diseases such as malaria, pneumonia, diarrhoea, measles and HIV/AIDS account for more than 70 per cent of the estimated one million under-five deaths in Nigeria (WHO, 2013). UNICEF (2013) lamented that malnutrition is the underlying cause of morbidity and mortality of a large proportion of children under-5 in Nigeria. It accounts for more than 50 per cent of deaths of children in this age bracket. The deaths of newborn babies in Nigeria represent a quarter of the total number of deaths of children under-five.

Many of these deaths are preventable with MCH services. Presently, less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants (UNICEF, 2013). This justifies the need for provision of maternal and child health interventions.

Addisse (2003) outlined the important considerations and justifications for provision of MCHS thus: (i) Mothers and children make up over 2/3 of the whole population. (ii) Women in reproductive age (15 – 49) constitute 21 per cent, pregnant women, 4.5 per cent, and children under the age of 5, 47 per cent. This working estimate may be very important in developing countries for project planning and implementation. (iii) Maternal mortality is an adverse outcome of many pregnancies. (iv) Miscarriage, induced abortion, and other factors, are causes for over 40 per cent of the pregnancies in developing countries to result in complications, illnesses, or permanent disability for the mother or child.    (v) About 80 per cent of maternal deaths are related to obstetric deaths. They result from obstetric complications of the pregnant state (pregnancy, labour, and puerperium), from intervention, omissions, incorrect treatment, or from a chain of events resulting from any of the above. (vi) Most pregnant women in the developing world receive insufficient or no prenatal care and deliver without help from appropriately trained health care providers. More than 7 million newborn deaths are believed to result from maternal health problems and their mismanagement. (vii) Poorly timed unwanted pregnancies carry high risks of morbidity and mortality, as well as social and economic costs, particularly to the adolescent and many unwanted pregnancies end in unsafe abortion. (viii) Poor maternal health hurts women's productivity, their families' welfare, and socio-economic development. The foregoing justifies the importance of MCHS.

Addisse (2003) noted that cultural attitudes and practices impede women's use of MCH services that are available. The women also lack access to relevant information, trained providers and supplies, emergency transport, and other essential services. Addisse maintained that because many women are fed less, marry early, carry a heavy workload, and spend a considerable portion of their lifespan in pregnancy and lactation, they are exposed to persistent low nutritional status and high-energy expenditure. This predisposes mothers to bear low-birth-weight infants.

Demographic factors associated with the extent of utilization of MCH services.

Certain variables have been found to influence the extent of provision and utilization of MCH services. One of such variables is economic status. It is well known that increased income has a positive effect on the utilization of modern health care services (Elo, 1992; Fosu, 1994). The study conducted by Nitai,  Islam, Chowdhury, Bari and Akhter (1993) revealed that women whose husbands worked in business or services were most likely to be users of modern health care services to treat complications during pregnancy. About 33.4 per cent of women whose husbands worked in business or services went to some qualified medical personnel for treatment, compared with 24 per cent among those whose husbands worked in agriculture or as day laborers. Also, women's involvement in gainful employment empowers women to take part in decision-making processes about health care in the family. About 35.4 per cent of women who worked for cash went to some qualified medical personnel for treatment, compared with only 25.3 per cent of those who did not work. Husband's occupation can be considered a proxy of family income, as well as social status. Audo, Ferguson and Njoroge (2005) reported that poor utilization of MCH services was associated with the socio-economic status of the respondents.

Differences in attitudes to modern health care services by occupational groups depict occupation as a predisposing factor. Alternatively, viewing occupation as proxy to income, which enables acquisition of more and better health care, depicts it as an enabling factor (Fiedler, 1981).  Vanden, De Mey, Buddingh and Bots (1999) found that unemployment and being without a husband were associated with deliveries outside the hospital. The patients may not have known their expected day of delivery (EDD) because they do not get antenatal services. Unaffordable medical bills is a major barrier to utilization of maternal and child healthcare services leading to a very high maternal and perinatal mortality and the inability to attain the MDG4 and MDG5 in many developing countries (Okafor, Obi & Ugwu, (2011).

The result of the study conducted by Kiwanuka, Ekirapa, Peterson, Okui, Rahman, Peters and Pariyo (2008) indicated that the poor and vulnerable ones experience a greater burden of disease and have lower access to health services than the rich ones. Mwaniki, Kabiru and Mbugua (2002) reported that lack of money for transport and hospital fee are the major constraints experienced by the mothers as they sought for the services. IRIN News (2006) reported that the patients' inability to afford prescribed medications is some of the challenges health officials are now facing.

The level of utilization of MCH services is still very low even with the introduction of the free MCH services. Suffice this to say that lack of or low level utilization of MCH care is not only due to financial reasons. Other factors have been consistently reported to influence the level of utilization of MCH care. One of such factors is the mother’s level of education.

It is well recognized that mother's education has a positive impact on health care utilization. Nitai,  Islam, Chowdhury, Bari and Akhter (1993) investigated the determinants of the use of maternal health services in rural Bangladesh and found that there were more educated women (34.6% ) than uneducated ones (26.5%) who sought care from qualified medical personal for treating complications. The study revealed that mother's education associated positively with treatment received. Govindasamy and Ramesh (1997) reported that a higher level of maternal education results in improved child survival because health services that effectively prevent fatal childhood diseases are used to a greater extent by mothers with higher education than by those with little or no education. The study further reported that the benefits of maternal education persist even when other socioeconomic factors are taken into account. Elo (1992) reported quantitatively important and statistically significant effect of mother's education on the use of prenatal care and delivery assistance. In another study conducted by Becker, Peters, Gray, Gultiano and Blake (1993), it was found that mother's education is the most consistent and important determinant of the use of child and maternal health services.

It is argued that better educated women are more aware of health problems, know more about the availability of health care services, and use this information more effectively to maintain or achieve good health status. Mother's education may also act as a proxy variable of a number of background variables representing women's higher socioeconomic status, thus enabling her to seek proper medical care whenever she perceives it necessary. UNICEF (1997) reported that education is positively associated with increased utilization of antenatal care. Nisar and White (2003) observed that there are a number of explanations why education is a key determinant of demand. The authors maintained that education is likely to enhance female autonomy. Women therefore, develop greater confidence and capabilities to make decisions regarding their own health, as well as their children’s health. It is likely that more educated women seek higher quality services and have greater ability to use health care inputs to produce better health. In addition to maternal education, age of the mother may play important role in the utilization of MCHS.

Mother's age may sometimes serve as a proxy for the women's accumulated knowledge of health care services, which may have a positive influence on the use of health services. On the other hand, because of development of modern medicine and improvement in educational opportunities for women in recent years, younger women might have an enhanced knowledge of modern health care services and place more value upon modern medicine. Nitai,  Islam, Chowdhury, Bari and Akhter (1993)  reported that older women are more likely to seek maternal health-care services than younger women. About 42 per cent of older (age >35 years) respondents sought care for any current complication from a doctor or nurse, compared with 28.5 per cent of younger women     (age <20 age="" also="" at="" em="" indicated="" marriage="" report="" that="" the="" years="">p

 < 0.10) associated positively with treatment received.

The report of Owino (2012) contradicted the above finding. Owino reported that maternal age also had a statistically significant relationship with place of delivery; the chances of delivering at home were greatest among older mothers aged 35 years and above; and the youngest age group, of mothers aged from 15 to 24, had the most chances of delivering at a health institution. Moreover, a greater percentage of mothers who delivered at health institutions were lower parity women with 1 to 3 children. Over 70 per cent of mothers of parity 7 and above delivered at home, compared to about 54 per cent of those of parity 1 to 3.

The above relationships of age and parity concur with previous studies (such as Dissevelt, 1978; Nginya, 1980; Winikoff, 1987; Obemeyer & Potter, 1991; Sargent & Rawlings, 1991; Bulut, 1995) where it was reported that younger women tended to deliver at a health facility for fear of complications during childbirth. Older women, however, were observed to deliver at home confidently due to their experience with previous births.

Some authors believe that one would naturally seek care irrespective of one’s age. This means that mother’s age has no connection with the attitude to and practice of safe motherhood.  Igbokwe and Adama (2011) reported that age had no significance influence on child-bearing mother’s practice of SMI components. The authors maintained that age of an individual does not necessarily influence the individual's capacity to effectively practice health-related behaviour most especially when the behaviour is of immense benefit to the individual.

Studies show that home-hospital distance influences the level of utilization of MCH services. The location and quality of services available are also important factors affecting MCH services utilization. Proximity to a health facility has been found to affect the use of MCH services especially in rural areas (Rahaman et al, 1982 in Chakraborty et al, 2003) as these facilities are usually located at long distances. For many, lack of transportation and/or considerations of the cost of transportation serve as mitigating factors to healthcare seeking.

Several other studies also found that physical proximity of health care services, especially in the developing countries, plays an important role in utilization of these services (Stock, 1983; Airey, 1989; Paul, 1991). In this study, ‘access’ refers to the availability of MCH services in closer proximity to the users. Rahaman (1982) reported that geographical distance is one of the most important determinants of health care service utilization in rural areas. World Bank (1999) and WHO (2012) listed distance, lack of information, inadequate services, cultural practices among others as the obstacle to the utilization of MCHS. The present study focuses on mother’s economic status, level of education, age and distance as they influence the extent of utilization of MCH services.

          Figure 1 above is the conceptual framework generated by the present researcher in explaining the level of provision and utilization of free MCH services among the child-bearing mothers and their children. There are two routes to getting MCH services: route A and B.

When sickness strikes or when there is need to seek medical attention, one is always confronted with obstacle that might hinder one from getting the right type of medical attention. One might choose any of the routes. Route A above is when the patients resiliently seek care notwithstanding factors such as financial constraints, distance among others. When one passes through obstacles, the route is always rough. The dotted arrow in route A indicates rough route. The patient eventually accesses the MCH services.

          Route B is an escapist and seemingly easier route from on set. The patient makes a U-turn in the face of an obstacle. She takes an alternative decision which might be to ignore the sign or to pray. Some resort to alternative medicine. They complain of the medical bills, distance, unyielding husband, cultural barriers among others, as factors hindering them from receiving care. This might lead to complications or worsened condition. Then, the patient would be rushed to the hospital through the roughest route ignoring cultural barriers and financial constraints indicted earlier.

Most times, complications may lead to maternal and child morbidity and/or mortality. There may be still birth, pre-term delivery among others.

Theoretical Frame Work

          Theories are constructs and postulations that guide or suggest a way in which individuals perceive phenomena and act or behave which in turn may influence the nature and the level of what they know or practice. The way individuals get information or behave is assumed or believed to depend on a person’s scheme (Illaete, 1980). The scheme attempts to know (knowledge), how they want to get the information (methods of learning) and how, what or which of the facts (knowledge) they want to act on (attitude). The theory is an idea or belief about something arrived through speculation or conjecture (Microsoft Encarta, 2009).

This study will therefore be anchored on theory of health seeking-behaviour and theory of attachment in explaining the level of provision and utilization of free MCH services among mothers of child-bearing age in Igbo-Eze North LGA of Enugu State.

Theory of health seeking-behaviour.

Health care utilization is the point in health systems where patients’ needs meet the professional system. It is well known that apart from need-related factors, health care utilization is also supply-induced and thus strongly dependent on the structures of the health care system. Furthermore, many study findings have shown differences in health care utilization based on patients’ social characteristics. For instance, women tend to use outpatient health care services more often than men. In addition to the multitude of studies describing patterns of utilization in different health care settings, several scholars have developed explanatory frameworks identifying predictors of health care utilization. One of the most widely acknowledged is the theory of health seeking-behaviour by Anderson and Newman (1973).

The theory has a multilevel model that incorporates both individual and contextual determinants of health services use. In doing so, it divides the major components of contextual characteristics in the same way as individual characteristics have traditionally been divided—those that predispose, enable , or suggest need for individual use of health services (Andersen, 2008). In their most recent explication of the model, Andersen & Davidson (2001) described these three major components as follows: (i) Predisposing factors. Individual predisposing factors include the demographic characteristics of age and sex as “biological imperatives” , social factors such as education, occupation, ethnicity and social relationships (e.g., family status), and mental factors in terms of health beliefs (e.g., attitudes, values, and knowledge related to health and health services). Contextual factors predisposing individuals to the use of health services include the demographic and social composition of communities, collective and organizational values, cultural norms and political perspectives.

Enabling factors are factors such as financing and organizational factors which are considered to serve as conditions enabling services utilization. Individual financing factors involve the income and wealth at an individual’s disposal to pay for health services and the effective price of health care which is determined by the individual’s health insurance status and cost-sharing requirements. Organizational factors entail whether an individual has a regular source of care and the nature of that source. They also include means of transportation, travel time to and waiting time for health care. At the contextual level, financing encompasses the resources available within the community for health services, such as per capita community income, affluence, the rate of health insurance coverage, the relative price of goods and services, methods of compensating providers, and health care expenditures. Organization at this level refers to the amount, varieties, locations, structures and distribution of health services facilities and personnel. It also involves physician and hospital density, office hours, provider mix, quality management oversight, and outreach and education programs. Health policies also fall into the category of contextual enabling factors.

The third factor is the need factors. At the individual level, there is difference between perceived need for health services (i.e., how people view and experience their own general health, functional state and illness symptoms) and evaluated need (i.e., professional assessments and objective measurements of patients’ health status and need for medical care). At the contextual level, they make a distinction between environmental need characteristics and population health indices. Environmental need reflects the health-related conditions of the environment (e.g., occupational and traffic and crime-related injury and death rates). Population health indices are overall measures of community health, including epidemiological indicators of mortality, morbidity, and disability.

According to Andersen and Newman (1973), the need factor is the most immediate cause of health service use. The need factor reflects the perceived health status, as indicated by severity of the morbidity conditions or the number of morbidities. The presence of predisposing and enabling components may not be enough for a mother to seek health care. She must perceive the disease as serious and believe that the treatment will provide the expected benefits (Fosu, 1994). Need represents the most immediate cause of health service use. The need for health care can be measured in a variety of ways: self-perceived health status, number of morbidity symptoms, or duration and severity of disability (Fiedler, 1981). Perceived severity or number of episodes of diseases has a positive association with greater MCH care utilization among the child-bearing mothers. However, this theory will be used in the present work to explain factors that determine the level of provision and utilization of MCH services.

Attachment theory.

Attachment theory focuses on the relationships and bonds between people, particularly long-term relationships including those between a patients and health-care provider. Attachment is an emotional bond to another person (Cherry, 2013). According to Ciechanowski, Walker, Katon and Russo (2002) Theory of Attachment is a framework of ideas that attempt to explain attachment, the almost universal human tendency to prefer certain familiar companions over other people, especially when ill, injured, or distressed. Psychologist, Bowlby (1969), was the first attachment theorist, describing attachment as a lasting psychological connectedness between human beings.

Bowlby (1969) believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life. He suggested attachment also serves to keep the infant close to the mother, thus improving the child's chances of survival. The central theme of attachment theory is that primary caregivers who are available and responsive to an infant's needs allow the child to develop a sense of security (Cherry, 2013). The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world.

This analogy can be extended to the patients-health providers relationship. People get attached to health providers who give them sense of health security. This is why a patient likes one doctor or nurse more than the other(s). If his/her doctor or nurse is no longer at the hospital (may be transferred), he/she finds it difficult to continue using the health services in the hospital. Moreover, a patient may have the same attachment to a particular hospital just as an infant knows that its care-giver is dependable. He/she believes that the hospital has genuine drugs, trained health personnel among other reason.

 

         

Figure 2 above is a theoretical framework adapted from the work of Fraley and Shaver. The researcher modified the framework to suit the present discourse. The double arrows linking the two theories are used to demonstrate that the two theories agree that people are always attracted to where things that catch their interest. When the patients’ needs (such as cost of medication, personnel of interest among others) are met in the arrow tagged “yes”, they feel loved, secured and confident, and level of MCH services utilization increases. Depression, anger and frustration set in when these needs are not met (see the arrow tagged “NO”). Patients may resort to withdrawal. Some patients may begin to look for another way out while others may remain at home not looking for alternate help.

Empirical Studies

Nitai,  Islam, Chowdhury, Bari and Akhter (1993) examined the factors that influence the use of maternal health care services in Bangladesh. Prospective data obtained from the survey on Maternal Morbidity in Bangladesh, which was conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT) was used. Data collection spanned the period from November 1992 to December 1993. The study had two components: cross-sectional and prospective. The paper employed data from the prospective component.

Multi-stage random sampling was employed to collect data on maternal morbidity. One district from each of four divisions was selected in the first stage. In the second stage, one thana (a thana contains several ‘unions’, comprising a population size of 0.2–0.25 million) from each selected district was selected randomly. Finally, two unions (unions consist of several ‘wards’, which are small geographical boundaries comprising villages in rural areas) from each selected thana were considered study areas. For the prospective study, 1020 pregnant women (pregnant for <6 1020="" 993="" antenatal="" at="" follow-up="" had="" interviewed.="" least="" months="" o:p="" of="" one="" out="" pregnant="" selected.="" were="" who="" women="">

The results showed that older women are more likely to seek maternal         health-care services than younger women. The results from the study indicated a U-shaped relationship with birth order and the use of health services to treat maternal morbidities.  The percentage of women who sought care from a doctor, nurse or FWV to treat any complications decreases from 29 per cent in women with no previous pregnancies to 26.1 per cent in mothers with one to four previous pregnancies; it increases again to 35.1 per cent in women with five or more previous pregnancies. The use of traditional and other health services related to the number of previous pregnancies also show a similar pattern.

The results show a U-shaped relation between family size and the use of health services for treating any complications during pregnancy. The percentage of women who sought care from qualified medical personnel, i.e. a doctor, nurse or FWV, to treat complications decreases from 30.3 per cent in women with less than four family members to 23.2 per cent among mothers with four to six family members, and increases again to 33.6 per cent in women with seven or more family members. The use of traditional and other health services does not show a similar pattern in relation to family size.

The results from this study also support the positive association between the level of mother's education and health care utilization. The results indicate that female education has a net effect on maternal health service use, independent of other background characteristics, household socioeconomic status and access to health care services. The percentage of women who sought care from qualified medical personal for treating complications increases from 26.5 per cent among illiterate women to 34.6 per cent among women with secondary or higher education.

The study revealed that women whose husbands worked in business or services were most likely to be users of modern health care services to treat complications during pregnancy. About 33.4 per cent of women whose husbands worked in business or services went to some qualified medical personnel for treatment, compared with 24 per cent among those whose husbands worked in agriculture or as day laborers. Also, women's involvement in gainful employment empowers women to take part in decision-making processes about health care in the family. About 35.4 per cent of women who worked for cash went to some qualified medical personnel for treatment, compared with only 25.3 per cent of those who did not work.

There was no substantial difference in utilization of health care services for complications according to how far respondents lived from health facilities. This result is quite surprising because the respondents residing in close proximity to health care services are more likely to use them. The study finally revealed that mother's education (p < 0.05), age at marriage (p < 0.10) and type of housing (p < 0.10) appeared to be associated positively with treatment received, while family size (p < 0.10) was negatively associated with receiving treatment for complications.

Vanden, De Mey, Buddingh, and Bots (1999) conducted a research which aimed at determining the coverage of antenatal and delivery care and the determinants of non-compliance in a rural area of Zimbabwe in order to improve the quality and efficiency of maternal health care services. A community-based, cross-sectional study was carried out in the catchment area of Gutu Mission Hospital, in rural Zimbabwe, from January to June 1996. Two hundred and thirty-five women, aged 16 to 54 years, who had delivered a child in the past three years, were interviewed on general characteristics (age, marital status, religion, education, work), obstetric history, use of family planning, pregnancy complications, number of antenatal visits, and use of maternity waiting shelters. Associations of these factors to non-use of antenatal care facilities and hospital delivery were studied. In the Gutu district, guidelines exist to identify women at high risk of complications during pregnancy and to indicate where women should give birth (hospital, rural clinic or at home). The study evaluated which factors were important for non-compliance to these guidelines. The analyses were performed using a logistic regression model.

Results show that 97 per cent of the pregnant women attended the antenatal care facilities at least once. 73 per cent came at least five times or more. The level of mother's education influenced health care utilization. Belonging to certain religious groups proved to be the strongest explanatory factor for not attending antenatal care facilities. Use of maternity waiting shelters and complications during the pregnancy were important factors for hospital delivery, whereas unemployment and being without a husband were associated with deliveries outside the hospital. Identification as high risk of a complicated pregnancy by application of the existing guidelines was not associated with place of delivery. Delivery at a location that did not conform to the existing guidelines was associated with non-use of maternity waiting shelters, unemployment or being without a husband and use of traditional care.

Kiwanuka, Ekirapa, Peterson, Okui, Rahman, Peters and Pariyo (2008) conducted a systematic review of socio-economic differences in morbidity and access to health care in Uganda. It includes published studies from electronic databases and official reports from surveys done by government, bilateral and multilateral agencies and universities.

The outcome measures studied were: the distribution of HIV/AIDS; maternal and child morbidity; and access to and utilisation of health services for people belonging to different socio-economic and vulnerability groups. Forty-eight of 678 identified studies met the inclusion criteria for the study. Results indicated that the poor and vulnerable experience a greater burden of disease but have lower access to health services than the less poor. Barriers to access arise from both the service providers and the consumers. Distance to service points, perceived quality of care and availability of drugs are key determinants of utilization. Other barriers are perceived lack of skilled staff in public facilities, late referrals, health worker attitude, costs of care and lack of knowledge.

Govindasamy and Ramesh (1997) conducted a study to ascertain the relationship between maternal education and the utilization of maternal and child health services in India. Using data from the National Family Health Survey 1992–93, they examined the relationship between maternal schooling and factors known to reduce the risks of maternal and child mortality, namely, healthcare practices, for some selected northern and southern states in India. They hypothesized that the practices of educated women are quite different from those of uneducated women with regard to pregnancy, childbirth, immunization, and management of childhood diseases such as diarrhoea and acute respiratory infection (ARI). However, there exist a number of confounding factors such as socioeconomic status that are associated with the study of the impact of maternal education on health-care utilization.

The hypothesis that the relationship between mother’s education and healthcare practices might be the result of other variables was tested, and regression analysis on several of these variables was carried out. It was evident that a higher level of maternal education results in improved child survival because health services that effectively prevent fatal childhood diseases are used to a greater extent by mothers with higher education than by those with little or no education. The study concluded that the benefits of maternal education persist even when other socioeconomic factors are taken into account.

Ditekemena (2013) conducted a study which aimed at identifying the determinants of male partners’ involvement in MCH activities, focusing specifically on HIV prevention of maternal to child transmission (PMTCT) in sub-Saharan Africa. Source of information was through the following data bases: Pubmed/MEDLINE; CINAHL; EMBASE; COCHRANE; Psych INFORMATION and the websites of the International AIDS Society (IAS), the International AIDS Conference and the International Conference on AIDS in Africa (ICASA) 2011.

It was found that the majority of studies defined male participation as male involvement solely during antenatal HIV testing. Other studies defined male involvement as any male participation in HIV couple counseling. The study identified three main determinants for male participation in PMTCT services: 1) Socio-demographic factors such as level of education, income status; 2) health services related factors such as opening hours of services, behavior of health providers and the lack of space to accommodate male partners; and 3) Sociologic factors such as beliefs, attitudes and communication between men and women.

It was concluded in the study that there are many challenges to increase male involvement/participation in PMTCT services and that few interventions addressing these challenges have been evaluated and reported. The study recommended that improvement of antenatal care services by making them more male friendly, and health education campaigns to change beliefs and attitudes of men are absolutely needed.

As unaffordable medical bills is a major barrier to utilization of maternal and child healthcare services leading to a very high maternal and perinatal mortality and the inability to attain the MDG4 and MDG5 in many developing countries, Okafor, Obi and Ugwu (2011) conducted a study which examined the uptakes of obstetric services following introduction of Free Maternal and Child Health Care (FMCHC) in Enugu State University Teaching Hospital, Southeast Nigeria and its impact on the maternal and neonatal healthcare outcome.

Information from a retrospective comparative study of the utilizations of maternal and child healthcare services from June to August in 2008 with that of September to November in 2008 after commencement of the FMCHC were utilized. Information on all the pregnant women and neonates in their first week of Life that attended clinic within the period under review was collected from the Medical Records department of the hospital.

The study revealed that FMCHC caused tremendous increases in the uptakes of antenatal booking (202.2%), and hospital delivery (151.8%). It also resulted in decreased maternal and perinatal mortality by 16.4 per cent and 34 per cent respectively. It was concluded in the study that implementation of FMCHC can make MDG4 and MDG5 attainable in sub-Saharan Africa.

Banerjee (2009) investigated the level of information, education, and communication (IEC) services regarding pregnancy and child care, received by the women at an MCH clinic of an urban health center of Kolkata. A community-based, cross-sectional, observational study was undertaken over a period of six months, in an urban health centre (UHC) of Kolkata that caters to a mixed population of 1.18 from all sections of the community. The study subjects comprised 400 antenatal (AN) and postnatal (PN) mothers and mothers of children under five (U5) years.

To determine sample size, P was taken as 0.5, considering the theory of probability that 50 per cent are likely to have received the services, which also gives the maximum sample size. Thus, sample comprised 400 women, considering 95 per cent confidence interval and allowing 10 per cent error.

The number of under 5 children was noted from the records, and the estimated number of AN and PN mothers at one point of time were calculated from the birth rate and population of the area during the previous year. To determine the size of these different groups within the sample, approximately 15 per cent of the total population in each group was taken. Thus, the sample comprised 350 U5 children and 50 AN and PN mothers. Only one person was selected from each household if more than one eligible participant was found.

Data was collected by house visits and interview method, using a pre tested, semi structured schedule which included IEC services, received by the mothers, regarding important points about pregnancy and child care, in the AN and PN period. Proportion of women receiving such services regarding issues under consideration was analyzed.

Results show that warning signs of danger was explained to only 10 per cent of the AN and PN women. Advice regarding family planning appeared to be the most frequently covered, though that too was explained to less than half of the subjects. About one third of the women were advised on breast feeding. Only 8 per cent of the mothers had been told about all issues regarding pregnancy and child care. Breast feeding and weaning was properly explained to 85.7 and 81.1 per cent of the total mothers of U5 children. Advice regarding subsequent nutrition was given to 60.9 per cent of mothers. About only a quarter of the total mothers were advised on home management of diarrhea and acute respiratory infections. Very few mothers were counseled about the growth pattern of the children and none were shown the growth chart. Only 12.9 per cent of the mothers were informed about all issues.

Based on the findings above, it was concluded that provision of information, education, and communication regarding maternal and child care other than feeding practices was a neglected service in the health facility where the study was conducted.

Materia, Mehari, Mele, Rosmini, Stazi,  Damen, Basile, Miuccio, Ferrigno and Miozzo (1993) conducted a community survey on maternal and child health services utilization in rural Ethiopia. Cross sectional research design was employed in the study. The instruments used for data collection were interview and focus group discussion.

 A household health interview survey on MCH services utilization was carried out among mothers of child bearing age in 22 villages of a rural district of Arsi region, Ethiopia, before the launching of an integrated MCH programme.

The result showed that the coverage of antenatal services was 26 per cent and 61 per cent of the women who received antenatal care reported having had 3 or more visits. Antenatal care was positively associated with living within 10 km of the Health Centre. Twenty-eight percent of the mothers attended the under-5 clinic and most returned for 3 or more visits. In addition, 99 per cent reported having breast-fed their last child but more than 25 per cent started weaning only after the seventh month of age. Differences in practice of treating diarrhoea according to knowledge of ORS were found. Of the 33 per cent of those with knowledge of ORS, almost 90 per cent reported use of ORS for treating child's diarrhoea, showing a positive attitude towards modern health care. The proportion of women using family planning was 5 per cent, with no difference found between Christians and Muslims.

Audo, Ferguson and Njoroge (2005) the quality of care provided by the Kisumu Municipal health facilities in Kenya, and its effects in the utilization of maternal and child health (MCH) services. A descriptive cross-sectional survey was employed in studying a total of 482 mothers. Interview was the instrument used for data collection.

The result of the study revealed that only 40.4 per cent, 53.7 per cent and 45.7 per cent had respectively used Municipal facilities for antenatal services (ANC), immunization and treatment of their children the last time they required such a service. This translates to by-pass rates for Municipal health facilities of 59.5 per cent, 46.3 per cent and 54.3 per cent respectively for the three services. By-pass was higher for the more central urban catchment areas than the more peripheral ones, a finding that was associated with the socio-economic status of the respondents and the relative location of the municipal facilities vis-a-vis competing facilities, mainly the District and Provincial hospitals.

The main reasons cited for by-pass were poor care (21%), lack of drugs and supplies (17%) and lack of/poor laboratory services (12%). From the facility audit, most of the clinics had a reasonable capacity to offer basic health care with only three scoring less than 50 per cent in the scale used. The worst areas were in availability of drugs, equipment and management issues. There was a strong relationship between the perceived quality of care and utilization of MCH services as well as by-pass. The capacity of the facilities to offer care was however not associated with utilization of MCH services or by-pass. However, it was concluded in the study that there is under-utilization of Municipal health facilities for MCH services. This is related to the perceived poor quality of care in the facilities. Perception of quality is influenced by a person's socio-economic status especially education.

Mwaniki, Kabiru and Mbugua (2002) researched utilization of antenatal and maternity services by mothers seeking child welfare services in Mbeere District, Eastern Province of Kenya. The Cross-sectional, descriptive research design was employed in the study. Two hundred mothers bringing their children aged one year and below to the child welfare clinic between September and December 2000 were studied.

The study revealed that the proportion of mothers who utilized health facilities for antenatal and maternity services was 97.5 per cent and 52 per cent, respectively. Utilization of health facilities for maternity services was significantly influenced by number of children and distance to health facility in that, as number of children increased, utilization of maternity services reduced. Mothers living less than 5 km to a health facility utilized the services better than those living 5 km and beyond. Among the reasons given by the mothers (individual respondents and through Focus Group Discussions) regarding dissatisfaction with the services offered included shortage of drugs and essential supplies, lack of commitment by staff, poor quality of food and lack of cleanliness in the health facilities.

Coverage for antenatal services was high among mothers during their last pregnancy. However, only about half of the mothers interviewed utilized health facilities for maternity services (labour and delivery). The major constraints experienced by the mothers as they sought for the services (as reported by individual respondents and through Focus Group Discussions) included lack of transport, lack of money for transport and hospital fee and delay in admission to health facility once mothers report in labour.

Kongnyuy, Hofman, Mlava, Mhango and Van Den (2009) investigated the availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi. The study surveyed of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183).

Result of the study shows that there were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23 per cent of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7 per cent. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0 per cent. Up to 86.7 per cent of pregnant women attended antenatal clinic at least once and only 12.0 per cent of them attend postnatal clinic at least once. There was a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed.

The total number of CEmOC facilities was adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts.

Vallières, McAuliffe, Palmer, Magbity and Bangura (2013) conducted a research which assessed the effects of both mobile phones and 7-11 timed and targeted counseling (7-11/ttC) mobile application on health workers’ motivation and health care service delivery structures in Sierra Leone given that Sierra Leone is consistently ranked among the countries with the highest maternal mortality ratio (970 per 100,000), and that women in Sierra Leone have a 1 in 21 lifetime risk of dying as a result of pregnancy. The main objective of the research was to examine changes in Community Health Workers’ motivation, triggered by the introduction of the 7-11/ttC mobile application, and assess how this mediates health worker performance over time. Motivation levels will be assessed in conjunction with other factors including: supervision, organisational commitment, and job satisfaction. 

A longitudinal cohort design to monitor individual and group changes in motivation, organizational commitment, supervision and job-satisfaction across three intervention groups over a period of 18 months was employed.  Participants were initially contacted from a list of active CHWs in the area, provided by the Bonthe District Health Management Team (DHMT). All 333 community health workers on the mainland in addition to one in-charge member of staff from all 26 health care centres in the area were asked if they were willing to participate in the study.  Within this sample size, both males and females were represented equally as part of the selection criteria for CHWs within each PHU. In order to ensure that all CHWs had the same basic level of 7-11/ttC training, CHWs completed the 7-11/ttC training jointly conducted by the DHMT and World Vision.

The results from systematic reviews of CHW programmes confirmed that CHWs provided critical links between rural communities and the formal health system and have been shown to reduce child morbidity and mortality when compared to usual healthcare services. The study also revealed that CHWs’ potential however, is hampered by inadequate supervision, lack of locally relevant incentive systems, loss of motivation, insufficient recognition and community support, poor connectivity to health facilities, and knowledge retention problems. Moreover, it was found that higher attrition rates are often associated with programmes where CHWs are asked to volunteer.

The study recommended that with appropriate support and sufficient training, CHWs can potentially play a pivotal role in strengthening health systems in areas with poor human resources for health.  More specifically, they are an important resource for implementing interventions targeting reductions in neonatal mortality and tracking women throughout their pregnancy while simultaneously promoting appropriate maternal and newborn care practices. It was concluded in the study that the motivation of CHWs and the risk of high attrition rates therefore have important implications for the effectiveness, success, cost, credibility and continuity of CHW-based programmes.

IRIN News (2006) reported a finding on the side effects of free maternal and child health services in Burundi. The source of information was through the mothers and children hospital health records. The reports revealed that a new policy of free medical care for Burundian mothers and children was intended to improve their lives; instead it has crippled the nation's health system; that public hospitals in Burundi have recorded double, sometimes triple, the number of patients since a presidential directive for free paediatric and maternal health services was implemented on 1 May; and that overcrowded wards, a shortage of doctors and other medical staff, as well as patients' inability to afford prescribed medications are some of the challenges health officials are now facing.

The study recommend that the government should increase medical staff, compel all health centres to remain open 24 hours and reinforce weekend teams to cope with the growing influx of patients. In addition to recruiting more staff, the government needed to increase salaries in order to stem an exodus of doctors from government service. 

Summary of Literature Review

          The focus of the present study is to investigate the level of provision and utilization of free MCH services among the child-bearing mothers in Igbo-Eze North LGA of Enugu State. Literature revealed that Nigeria is second country (after India) with highest cases of maternal and child mortality and morbidity. This led to the introduction of free MCH services in most states in Nigeria including Enugu State. Yet, literature consistently report that there is still high rate of maternal and child mortality and morbidity.

          In the present study, the free MCH services  are those free health services given to mothers and their children regardless of their ability to pay for the services in order to reduce the rate of maternal and child death and achieve the optimal health of both the mother and her child. Provision and utilization of MCH services remains the only proven tool for reducing the rate of maternal and child mortality. Definitions of concepts such as provision, utilization, and extent as given by different authors were x-rayed.

Certain variables have been found to influence the extent of provision and utilization of MCH services. One of such variables is economic status. Increased income was documented to have a positive effect on the utilization of modern health care services. Also, women's involvement in gainful employment empowers women to take part in decision-making processes about health care in the family.

Mother’s level of education was also shown to influence the extent of utilization of MCH services. It is argued that better educated women are more aware of health problems; know more about the availability of health care services; and use this information more effectively to maintain or achieve good health status. It was also found that a higher level of maternal education results in improved child survival because health services that effectively prevent fatal childhood diseases are used to a greater extent by mothers with higher education than by those with little or no education.

Apart from mother’s level of education, age of mother was also shown to influence the extent of utilization of MCH services. Findings on how age influences health care utilization are not consistent. Some reports show that older women utilize health services more than their younger counterparts but the reverse is reported by some other studies. The third school of thought believes that one would naturally seek care when distressed irrespective of one’s age. This means that age has no influence on the mothers’ extent of utilization of health services.

The location and quality of services available are also important factors affecting MCH services utilization. Proximity to a health facility has been found to affect the use of MCH services especially in rural areas as these facilities are usually located at long distances. For many, lack of transportation and/or considerations of the cost of transportation serve as mitigating factors to healthcare seeking.

The theories of anchor in the present study are: the theory of health seeking-behaviour by Anderson and Newman (1973) and the attachment theory by Bolby (1969). The tenet of the theory of health seeking-behaviour is that utilization of health services depends the predisposing (such age, gender etc); enabling factor like income level; and need factor (perceived needs and evaluated needs). The tenet of the Attachment theory is that there is universal human tendency to prefer certain familiar companions over other people, especially when ill, injured, or distressed. 

Literature revealed that the rate of maternal and child mortality globally is unacceptably high especially in developing countries including Nigeria despite the widely publicized free health programmes and policies which target reduction of maternal and child mortality. This led to copious studies on the extent of provision and utilization of free maternal and child health services. However, most of the literatures on the topic describe the situation as it exists elsewhere. None of such studies, to the best of the knowledge of the present researcher, has been conducted in Igbo-Eze North Local Government of Enugu State. The present study fills the gap.

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