International Journal of Gynecology and Obstetrics ...

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Nonye Aniebue ^, Charles West ^. ' Nationa/Primao" Health Care Development Agency, Abu/a, Nigeria. Duke Global Health Institute. Duke University. Durham.
International Journal o f Gynecology a n d Obstetrics 117 (2012)

51-65

Contents lists available at SciVerse ScienceDirect I ; v \ i ' c 1 i i . i «.> (Hwn:ri;ic s

International Journal o f Gynecology and Obstetrics

•

journal homepage: www.elsevier.com/locate/ijgo

w w w . f i g o . o r g

HI

CLINICAL ARTICLE

Prenatal care a n d basic e m e r g e n c y obstetric care services p r o v i d e d at p r i m a r y healthcare facilities i n rural Nigeria . . . U g o O k o l i ^•*, M o h a m m e d J . A b d u l l a h i ^ M u h a m m a d A . P a t e N o n y e A n i e b u e ^, C h a r l e s W e s t ^

I s a S. A b u b a k a r

' N a t i o n a / P r i m a o " H e a l t h Care D e v e l o p m e n t Agency, Abu/a, Nigeria D u k e G l o b a l H e a l t h I n s t i t u t e . D u k e University. D u r h a m . USA ' D e p a r t m e n t of C o m m u n i t y M e d i c i n e . Bayero University. Z a r i a . Nigeria ' ' D e p a r t m e n t of C o m m u n i t y M e d i c i n e , University of Nigeria. Enugu, Nigeria ' D e p a r t m e n t of C o m m u n i t y M e d i c i n e . University of P o r t H a r c o u r t , P o r t H a r c o u r t , N i g e r i a

A R T I C L E

I N F O

Article history: Received 12 July 2 0 1 1 Received in revised f o r m 5 November Accepted 21 December 2011 Keywords: Basic e m e r g e n c y o b s t e t r i c care Maternal newborn and child health M i d w i v e s Service Scheme Nigeria Prenatal care P r i m a r y h e a l t h care

A B S T R A C T Objective: T oassess t h e a v a i l a b i l i t y o f p r e n a t a l care a n d basic e m e r g e n c y o b s t e t r i c care services a t p r i m a r y healthcare (PHC) 2011

Service

Scheme,

facilities i n rural Nigeria. Methods: I n total, 6 5 2 P H C facilities enrolled i n t h e a government-funded

program designed t oreduce

the national shortage

Midwives

o fskilled

attendants, w e r e surveyed. Results: I n all,44.0% o f t h e P H C facilities evaluated did n o t provide all

birth

components

o f p r e n a t a l care, a n d o n l y 3 9 . 0 % o f all p r e g n a n t w o m e n n a t i o n w i d e a t t e n d e d p r e n a t a l care clinics 4 o r times. I n addition, 52.2% o f t h e facilities w e r e n o t d i s t r i b u t i n g insecticide-treated w h i l e o n l y 36.8% o f t h e PHC facilities provided

nets to pregnant

services t oprevent m o t h e r - t o - c h i l d t r a n s m i s s i o n o f HIV. By

contrast, 70.0% o f t h e PHC facilities h a d access t o antibiotics for t h e t r e a t m e n t o f u n c o m p l i c a t e d O n l y 11.0% o f clinics reported the use o f v a c u u m extraction d u r i n g labor a n d 36.8% provided care services. T r e a t m e n t for pre-eclampsia respectively,

p r i o r t o r e f e r r a l . Conclusion:

more

women, sepsis.

post-abortion

a n d eclampsia w a s initiated at 4 0 . 0 % a n d 2 8 . 0 % o f P H C facilities, The present

study provides

useful i n f o r m a t i o n o nt h e state o f

prenatal a n d basic e m e r g e n c y obstetric care i n rural Nigeria. T h e data o b t a i n e d indicate t h a t changes needed to achieve related M i l l e n n i u m Development

® 2 0 1 2 International Federation o f Gynecology a n d Obstetrics. Published by Elsevier Ireland Ltd. All

1. Introduction N i g e r i a is t h e m o s t p o p u l o u s c o u n t r y i n A f r i c a w i t h o v e r 1 4 0 m i l l i o n people. W o m e n o f child-bearing age a n d c h i l d r e n u n d e r 5 years o f age m a k e u p a n appreciable p r o p o r t i o n o ft h e nation's p o p u l a t i o n ( 2 3 % a n d 2 0 % , r e s p e c t i v e l y ) [ 1 ]. N i g e r i a a l s o a c c o u n t s f o r 1 0 . 0 % o f t h e w o r l d ' s a n n u a l m a t e r n a l a n d c h i l d h o o d (i.e. u n d e r 5 y e a r s ) m o r t a l i t y , d e s p i t e the fact t h a t o n l y 2.0% o ft h e total global p o p u l a t i o n live i n Nigeria. T h e m a t e r n a l m o r t a l i t y r a t i o i n N i g e r i a is 5 4 5 p e r 1 0 0 0 0 0 l i v e b i r t h s |1]. T h e a v a i l a b i l i t y o f s k i l l e d b i r t h a t t e n d a n t s is less t h a n 4 0 % n a t i o n w i d e , a n d 3 6 % o f p r e g n a n t w o m e n d o n o t r e c e i v e p r e n a t a l c a r e [ 1 ]. Current trends demonstrate the slow rate of progress being m a d e i n Nigeria t oachieve the international M i l l e n n i u m D e v e l o p m e n t Goals using e x i s t i n g strategies a l o n e [2]. M a t e r n a l m o r t a l i t yr e m a i n s a m a j o r public-health challenge i n Nigeria, despite t h e policies a n d strategies to reverse this t r e n d [3].

* Corresponding a u t h o r at: National P r i m a r y H e a l t h Care D e v e l o p m e n t Agency, Plot 681/682 Port H a r c o u r t Crescent, Area 1 1 , Garki, Abuja, Nigeria. Tel.: + 2 3 4 8031973001. E-mail address: u o k o l i 2 @ y a h o o . c o m ( U . O k o l l ) .

are

Goals. rights

reserved.

T o ensure that Nigeria's a i m to achieve the M i l l e n n i u m D e v e l o p m e n t Goals related to child m o r t a l i t ya n d m a t e r n a l health remains o n track, the Nigerian g o v e r n m e n t resolved to strengthen facility based m a t e r n a l a n d child h e a l t h services across t h e rural parts o f t h e country, t h r o u g h the establishment of t h e M i d w i v e s Service Scheme (MSS). This p r o g r a m is d e s i g n e d t o a d d r e s s t h e s h o r t a g e o fs k i l l e d b i r t h a t t e n d a n t s a t t h e p r i m a r y healthcare (PHC) level. U n e m p l o y e d , n e w l y graduated, and retired (but physically able) m i d w i v e s w e r e engaged u n d e r the MSS. These m i d w i v e s w e r e posted t o selected P H C facilities i n rural c o m m u nities to increase skilled attendance at birth and to help reduce maternal, n e w b o r n a n d child m o r t a l i t y . T h e M S S facilities are l i n k e d i n a n effective 2 - w a y referral s y s t e m t h r o u g h a cluster m o d e l i n w h i c h 4 P H C facilities w i t h t h e capacity t o provide basic essential obstetric care are clustered a r o u n d a secondary care facility w i t h t h e capacity to prov i d e c o m p r e h e n s i v e e m e r g e n c y obstetric care. T h e m a j o r causes o f m a t e r n a l m o r t a l i t y i n Nigeria are hemorrhage, sepsis, eclampsia, o b s t r u c t e d labor, a n d c o m p l i c a t i o n s o f i n d u c e d a b o r t i o n [4,5]. O v e r w h e l m i n g evidence exists t h a t t h e s e causes o f m o r t a l i t y can b e p r e v e n t e d i f prenatal care a n d basic e m e r g e n c y obstetric care ( B E m O C ) services are m a d e available [ 4 - 8 ] . P o o r access o f t h e s e s e r v i c e s b y p r e g n a n t w o m e n is e v i d e n t as o n l y 4 0 % o f d e l i v e r i e s o c c u r i n t h e p r e s e n c e o f s k i l l e d b i r t h a t t e n d a n t s [ 1 ]. T h i s t r e n d i s

0 0 2 0 - 7 2 9 2 / $ - see f r o n t m a t t e r © 2 0 1 2 International Federation o f Gynecology a n d Obstetrics. Published by Hsevier Ireland Ltd. A l l doi:10.1016/j.ijgo.2011.11.014

rights

reserved.

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particularly w o r r y i n g given t h a t P H C facilities represent t h e k e y e n t r y point into t h e Nigerian health system, a n d offer t h e o p p o r t u n i t y for prevention a n d treatment o f complications o f pregnancy, particularly among rural communities. T h e a i m o f t h e present s t u d y w a s , therefore, t o assess t h e a v a i l ability a n d provision o f a range o f prenatal a n d B E m O C services a t the P H C level i n rural areas o f Nigeria. A s such, t h e M S S provided a u n i q u e o p p o r t u n i t y t oevaluate these services, a n d t oidentify k e y aspects o f m a t e r n a l h e a l t h services i n need o f i m p r o v e m e n t .

2. Materials and methods T h e 6 5 2 M S S P H C facilities located w i t h i n t h e 6 geopolitical zones o f Nigeria w e r e i n v i t e d t o participate i n t h e present study. These facilities are designed t o provide maternal, n e w b o r n a n d child health ( M N C H ) services. T h e selection criteria included r e m o t e geographic location, covering a population o f 1 0 0 0 0 - 3 0 0 0 0 people, a n d providing M N C H services (also k n o w n as a type 3 facility). A f o r m u l a , calculated o n t h e basis o f m a t e r n a l m o r t a l i t y b u r d e n across t h e 6 geopolitical zones, w a s used t o d e t e r m i n e t h e n u m b e r o f P H C facilities i n each zone. A n e s t i m a t e d 1 3 0 0 0 PHCs provide M N C H services across Nigeria b u t n o t all a r e located i n rural areas. The survey w a s conducted f r o m January 18 t o 22,2010, a n d used a cross-sectional descriptive design. T h e required i n f o r m a t i o n w a s obtained f r o m t h e managers o f 6 5 2 rural PHCs using a semistructured i n t e r v i e w m e t h o d , a n d f r o m t h e P H C service activity registers. T h e questionnaire used i n t h e present study w a s adapted f r o m the W H O a n d the W o r l d Bank sample questionnaires previously used i n M N C H surveys i n Nigeria a n d other African countries. T h e questionnaire w a s r e v i e w e d a n d adapted t oreflect t h e p o p u l a t i o n a n d M N C H issues relevant t o Nigeria t h r o u g h a series o f w o r k s h o p s that involved various stakeholders, including the Nigerian governm e n t a n d n o n - g o v e r n m e n t a l organizations w o r k i n g i n Nigeria. T h e survey t o o l w a s pre-tested b y t h e managers o f 1 2 M S S P H C facilities located across 3 states. A supervisor a n d 4 field w o r k e r s w e r e recruited t o carry o u t t h e survey for 5 days i n a cluster o f 4 P H C facilities i n t h e 3 6 states plus t h e Federal Capital Territory. These w o r k e r s had a m i n i m u m o f secondary school level education, a n d w e r e fluent in reading a n d w r i t i n g b o t h English a n d a local language. T h e y w e r e trained w i t h guidelines produced for use d u r i n g t h e field i m p l e m e n t a t i o n . P r e n a t a l care, delivery, a n d p o s t n a t a l records w e r e r e v i e w e d ; this review included a n equipment inventory a n d assessment at t h e facilities t o d e t e r m i n e t h e availability a n d provision o f prenatal a n d B E m O C services. T h e supervisors w e r e responsible f o r validating t h e data collected b y observation a n d cross-checking t h e P H C facility inventory for equipment.

and Obstetrics

117 (2012)

61-65

In total, 6 5 2 P H C facilities w e r e surveyed b yt h e field w o r k e r s . Completed questionnaires w e r e r e t u r n e d for data processing, w h i c h included editing, coding open-ended questions, data entry, a n d data cleaning. Data entry a n d initial editing w e r e accomplished using ClSPro s o f t w a r e (ClSPro Systems, K e l o w n a , BC, Canada). F u r t h e r editi n g a n d data analysis w e r e p e r f o r m e d u s i n g SPSS (SPSS, Chicago, IL, USA). Ethical approval for t h e survey o f P H C facilities w a s n o t required f r o m t h e National P r i m a r y Health Care D e v e l o p m e n t Agency Ethics Review Board; however, permission w a s sought, a n d consent obtained, f r o m t h e State M i n i s t r y o f H e a l t h a n d t h e Local G o v e r n m e n t responsible f o r t h e P H C facilities. C o m m u n i t y leaders w e r e used t o link t h e field w o r k e r s w i t h t h e P H C facilities after o b t a i n i n g t h e i r full cooperation. 3. Results In all, 97.0% o f t h e 6 5 2 M S S P H C facilities s u r v e y e d w e r e f o u n d t o be p r o v i d i n g s o m e f o r m o f p r e n a t a l care (Fig. 1). T h o s e facilities n o t p r o v i d i n g prenatal care services h a d a shortage o f skilled staff a t t h e time o f t h e survey. For a l l M S S P H C facilities, t h e p r o p o r t i o n o fn e w prenatal care visits w a s 38.0% a n d proportion o f w o m e n m a k i n g 4 or m o r e prenatal visits w a s 39.0%. Table 1 s h o w s t h e proportions o f prenatal care visits b e t w e e n t h e P H C facilities a m o n g t h e 6 geopolitical zones. T h i s table also details t h e n u m b e r a n d p r o p o r t i o n o f w o m e n w h o received 2 o r m o r e doses o f tetanus t o x o i d d u r i n g prenatal care visits. O n average, 35.0% o f all w o m e n received 2 o r m o r e doses o f this vaccine at t h e M S S P H C facilities. A h i g h p r o p o r t i o n ( 4 4 % ) o f t h e P H C facilities surveyed d i d n o t p r o vide a l l c o m p o n e n t s o f p r e n a t a l care services. A b r e a k - d o w n o f t h e i n d i v i d u a l c o m p o n e n t s is presented i n Fig. 1. T h e s u r v e y s h o w e d t h a t 73.0% o f t h e M S S P H C facilities offered i n t e r m i t t e n t p r e v e n t i v e treatm e n t for m a l a r i a i n pregnancy. Notably, however, t h e survey also f o u n d t h a t 5 2 . 2 %o f t h e facilities w e r e n o t d i s t r i b u t i n g insecticidetreated nets t o pregnant w o m e n . Prevention o f mother-to-child transm i s s i o n o f H I V w a s c o n d u c t e d b y36.8% o f M S S facilities across t h e country. Data o n t h e provision of the individual components of BEmOC are presented i n Fig. 2 a n d Table 2. A m e a n o f70.0% o ft h e M S S P H C facilities h a d access t o antibiotics f o r t h e t r e a t m e n t o f u n c o m p l i c a t e d sepsis; 11.0% w e r e c o n d u c t i n g v a c u u m extraction; a n d 21.0% w e r e able t o p e r f o r m m a n u a l v a c u u m aspiration. O n l y 40.0% a n d 28.0% o f facilities w e r e f o u n d t o b e initiating t r e a t m e n t o f pre-eclampsia a n d eclampsia, respectively, a t t h e P H C level. Table 2 indicates that 36.8% o f M S S P H C facilities across t h e c o u n t r y h a d provision f o r p o s t - a b o r t i o n care services. O f t h e 6 geopolitical zones, 54.0% o f P H C

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73

Routine

Iron tablets Hemoglobin Urineprotc

prenatal care a n d folic acid provided

provided

analysis

analysis

Urineglucose analysis

IPTfor malaria

Distribution of ITNs

PMTCT services provided

Fig. 1 . Provision o f c o m p o n e n t s o f prenatal care services a t M i d w i v e s Service S c h e m e ( M S S ) p r i m a r y healthcare ( P H C ) facilities. T h e percentage o f M S S P H C facilities that provid each i n d i v i d u a l c o m p o n e n t o f prenatal care i ss h o w n . Abbreviations: IPT, i n t e r m i t t e n t preventive t r e a t m e n t for m a l a r i a i n pregnancy; rTNs, insecticide-treated nets; P M T prevention o f mother-to-child transmission o f HIV.

U O k o l i e t aL / International

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Table 1 M i d w i v e s Service Scheme ( M S S ) p r i m a r y healthcare ( P H C ) facility-based prenatal care

and Obstetrics

U 7(2012) 6 1 - 6 5

services.''

Geopolitical zones

M S S P H C facilities in each zone

Total prenatal care visits

New prenatal care visits

Prenatal care ( > 4 visits

N o r t h East North West North Central South-South S o u t h East South West Total

144 168 112 96 60 72 652

64 106 14 20 10 23 240

23 5 5 4 (36.0) 4 8 4 2 5 (46.0) 7068 (49.0) 3774(18.0) 3802 (35.0) 4340(18.0) 9 0 9 6 3 (38.0)

27 1 0 1 39 4 9 2 4285 6675 4721 10 5 7 5 92 8 4 9

472 130 540 502 856 986 485

63

attendance

(42.0) (37.0) (29.0) (33.0) (43.0) (44.0) (39.0)

W o m e n receiving tetanus toxoid ( > 2 doses) 19 2 0 3 31 3 1 5 6529 10 6 5 6 3066 12 3 2 4 83 0 9 3

(30.0) (30.0) (45.0) (52.0) (28.0) (51.0) (35.0)

' V a l u e s a r e g i v e n as n u m b e r o r n u m b e r ( p e r c e n t a g e o f total p r e n a t a l care visits).

facilities i n t h e N o r t h East z o n e p r o v i d e d p o s t - a b o r t i o n care, w h i l e the proportion for t h e N o r t h W e s t zone w a s 39.8%. For t h e other 4 zones, e a c h h a d less t h a n a t h i r d o f t h e i r P H C facilities p r o v i d i n g p o s t - a b o r t i o n care. I n a l l , 2 1 . 0 %o f t h e selected M S S P H C facilities h a d a functional m a n u a l v a c u u m aspirator set. Facilities i n S o u t h S o u t h z o n e h a d t h e least n u m b e r o f these devices (9.0%), w h i l e t h e range w a s 20.0%-26.0% i n t h e other 5 zones.

w h o attended a t least 4 prenatal care visits i n t h e survey area (39.0%) c o m p a r e d w i t h t h e w h o l e c o u n t r y (45.0%) [ 1 ]possibly r e flects t h e r u r a l s e t t i n g o f t h e s u r v e y ; o t h e r reasons c o u l d b elack o f awareness o f birth preparedness, attitude o f healthcare workers, n o n - a v a i l a b i l i t y o fh e a l t h c a r e w o r k e r s o r e q u i p m e n t , w o m e n ' s perception o f being i ngood health, a n d spouses a n d relatives disapprovi n g o f t h e u s e o f p r e n a t a l services [1,9].

T h e survey revealed that i n rural Nigeria, 3 0 . 0 % o ft h e selected M S S facilities w e r e n o t t r e a t i n g w o m e n w i t h u n c o m p l i c a t e d sepsis, notably i n t h e N o r t h W e s t a n d South W e s t zones (65.0% a n d 61.0%, respectively).

A t t e n d i n g prenatal care visits 4 o r m o r e times provides t h e opport u n i t y f o r p r e g n a n t w o m e n t o receive a package o f services referred to a s "focused prenatal care". S o m e African countries w i t h f e w e r resources t h a n Nigeria, such a s Ghana, M a l a w i , Rwanda, Uganda, and Zambia, have managed t om a i n t a i n m o r e t h a n 90.0% coverage o f prenatal care [10].T h e m a t e r n a l m o r t a l i t y rates i n these countries range f r o m 3 5 0 to 5 4 0 per 1 0 0 0 0 0 live births [11].

Fig. 2 s h o w s t h e p r o p o r t i o n o f M S S P H C facilities w i t h m e d i c a l t r e a t m e n t s available for BEmOC, such a sm a g n e s i u m sulfate, m i s o prostol, a n d anti-shock garments. M a g n e s i u m sulfate for t h e managem e n t o f eclampsia w a s available i n 27.0% o ft h e M S S P H C facilities n a t i o n w i d e a t t h e t i m e o f t h e survey. Misoprostol tablets, w h i c h could b e used for both treatment a n d prevention o f postpartum h e m o r r h a g e , w e r e available i n3 0 . 0 % o f M S S facilities across t h e n a t i o n , a n d a n t i - s h o c k g a r m e n t s w e r e f o u n d i n o n l y 1 2 . 0 %o ft h e facilities surveyed. 4. Discussion T h e care a n d assistance that w o m e n receive d u r i n g pregnancy i n fluences t h e morbidity a n d mortality o f m o t h e r a n d child. A pregnant w o m a n w h o lacks access t o g o o d q u a l i t y p r e n a t a l care w i l l n o t benefit f r o m t h e essential p r e v e n t i v e m e a s u r e s offered b y these services. I n the Nigerian population u n d e r discussion, 58.0% o f pregnant w o m e n receive prenatal care f r o m a skilled healthcare provider a t s o m e point during their pregnancy [1], I n t h e present study, 44.0% o f t h e PHC facilities surveyed d i d n o t provide a l l c o m p o n e n t s o f prenatal care services, w i t h m a r k e d variations i np r e n a t a l care attendance across different geopolitical zones. T h e l o w e r p r o p o r t i o n o f w o m e n

T h e c o n t e n t o f p r e n a t a l care is a n e s s e n t i a l p r e d i c t o r o f t h e q u a l i t y o f services offered. T h e p r e m i s e o f focused prenatal care is t h a t every pregnancy is a t risk o f complications a n d s h o u l d be m o n i t o r e d a p p r o priately. T h e results o f t h e present study are comparable t o data f r o m the 2 0 0 8 Nigeria Demographic a n d Health Survey [1], w h e r e 7 5 % o f pregnant w o m e n h a d a u r i n e sample taken, 5 4 % received i r o n tablets, and 4 5 % received 2o r m o r e doses of tetanus toxoid. T h ecoverage o f teta n u s vaccination ( 2 o r m o r e doses) i n Nigeria is m u c h l o w e r t h a n o t h e r W e s t African countries, s u c h as G a m b i a w h e r e coverage is 95.0% [10]. Furthermore, t h e Republic o fBenin a n d M a l a w i have both achieved certified e l i m i n a t i o n o f neonatal tetanus [12]. Findings f r o m a survey [13] provided several reasons w h y m o t h e r s i n Nigeria a r e n o t receiving tetanus toxoid: for example, unavailability o f the vaccine d u r i n g prenatal care visits a n d n o n - a w a r e n e s s o f its i m p o r t a n c e . In addition, a l l pregnant w o m e n should receive 2 single doses of intermittent preventive treatment for malaria during pregnancy. Furthermore, all pregnant w o m e n a n d children u n d e r 5years o f age a r e r e q u i r e d t o s l e e p u n d e r i n s e c t i c i d e - t r e a t e d n e t s . T h e findings o f the present study regarding malaria prevention clearly demonstrate

70

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"

liilhiii 36.*

H

_

Postabortion Functional Vacuum Useof Initiating Initiating Magnesium Misoprostol Anti-shock .'> . r ^ i . - r . care M V A set extraction antibiotics treatment of treatment of sulfate available garment available performed preeclampsia eclampsia available available F i g . 2. A v a i l a b i l i t y o f b a s i c e m e r g e n c y o b s t e t r i c c a r e ( B E m O C ) s e r v i c e s a t M i d w i v e s S e r v i c e S c h e m e ( M S S ) p r i m a r y h e a l t h c a r e ( P H C ) f a c i l i t i e s . T h e p e r c e n t a g e o f M S S P H C f a c i l i t i e s t h a t p r o v i d e d each i n d i v i d u a l c o m p o n e n t o f B E m O C is s h o w n . A b b r e v i a t i o n : M V A , m a n u a l v a c u u m aspirator.

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Table 2 Availability o f basic e m e r g e n c y m e d i c a l obstetric care services b y geopolitical zone.* Geopolitical zones

Post-abortion care

Functional manual vacuum aspirator set available

Vacuum extraction performed

Antibiotics available for uncomplicated sepsis

Initiating pre-eclampsia treatment before referral

Initiating eclampsia treatment before referral

Magnesium sulfate available

Misoprostol available

Anti-Shock garment available

N o r t h East North West North Central South-South S o u t h East South West Total

54.0 39.8 36.0 21.0 27.8 20.0 36.8

240 20.0 22.0 9.0 26.0 22.0 21.0

14.0 14.0 7.0 3.0 16.0 6.0 11.0

78.0 65.0 71.0 71.0 72.0 61.0 70.0

56.0 50.0 36.0 24.0 33.0 12.0 40.0

47.0 38.0 23.0 13.0 15.0 6.0 28.0

36.0 32.0 25.0 18.0 19.0 16.0 27.0

26.0 31.0 43.0 17.0 37.0 22.0 30.0

13.0 13.0 15.0 5.0 16.0 6.0 12.0

,

' V a l u e s a r e g i v e n as percentages.

an urgent need t oensure adequate supplies o f insecticide-treated nets t o P H C facilities i nNigeria, a s t h e y are a very effective a n d c h e a p m e t h o d o fp r e v e n t i n g m a l a r i a d u r i n g p r e g n a n c y [ 1 3 ] . E v e r y o p p o r t u n i t y t h a t presents d u r i n g p r e g n a n c y s h o u l d b eexploited, i n cluding participation i n t h e Roll Back Malaria p r o g r a m [14]. T h e present s u r v e y s h o w e d t h a t o n l y 36.8% o f M S S P H C facilities nationwide were conducting prevention o f mother-to-childtransmiss i o n o f H I V . T h i s f i n d i n g c o u l d reflect t h e fact t h a t s u c h p r e v e n t a t i v e m e a s u r e s h a v e n o t b e e n a r o u t i n e c o m p o n e n t o f p r e n a t a l care, p a r t i c ularly i n rural areas o f Nigeria [9], Infection w i t h H I Va n d subsequent d e v e l o p m e n t o f A I D S is b e c o m i n g t h e l e a d i n g cause o f d e a t h a m o n g w o m e n i n s o m e African countries [9]. Pregnant w o m e n are at a h i g h risk o f intrapartum a n d p o s t p a r t u m complications; however, opportunities for H I V counseling a n d testing, a n d t h e provision o f prevent i o n o fm o t h e r - t o - c h i l d t r a n s m i s s i o n services, a r e being m i s s e d a t the P H C level. A c r o s s t h e w o r l d , 15% o f a l l p r e g n a n t w o m e n d e v e l o p o b s t e t r i c complications, m o s t o f w h i c h are unpredictable i n nature [9]. Hence, it is essential that B E m O C services a r e m a d e available i n o r d e r t o prevent m a t e r n a l a n d neonatal death a n d disability. T h e results o f t h e present survey corroborate those o f a n a t i o n a l s t u d y o f B E m O C services [15],w h i c h s h o w e d that m a n y healthcare facilities lacked adequate material resources a n d obstetric instruments a n d equipment. T h e s a m e s u r v e y f o u n d t h a t 21.0% o f secondary healthcare facilities, a n d m o s t P H C facilities, h a d n o f u n c t i o n a l e q u i p m e n t f o r m a t e r n a l and child h e a l t h services [15]. T h e v a r i a t i o n s , a n d less t h a n a d e q u a t e p r o v i s i o n , o f p r e n a t a l care a n d B E m O C across t h e 6 geopolitical zones surveyed i n t h e present s t u d y i s apparent a n d reflects t h e range o f m a t e r n a l m o r t a l i t y i n Nigeria, w h i c h varies b e t w e e n 1 6 5 per 1 0 00 0 0 live births i n t h e South W e s t t o 1 5 4 9 per 1 0 00 0 0 live births i n t h e N o r t h East zone [1]. T h i s p a t t e r n i s replicated f o r n e o n a t a l m o r t a l i t y rates i n Nigeria [1]. B y contrast, h i g h - i n c o m e c o u n t r i e s w i t h c o n s i s t e n d y l o w m a t e r n a l a n d n e o n a t a l m o r t a l i t y rates, s u c h as S w e d e n , e n s u r e u n i v e r s a l access to B E m O C , v e r y h i g h prenatal care attendance, a n d 1 0 0 %availability of skilled birth attendants [16]. The limited i m p r o v e m e n t s at t h e P H C level demonstrated i n t h e p r e s e n t s u r v e y m a y b e d u e t o several factors, s u c h as lack o f political will a n d c o m m i t m e n t o f t h e g o v e r n m e n t t o p u t m o r e resources i n PHC over t h e years. However, t h e adoption o f t h e n e w National Health Strategic Plan i n 2 0 1 0 [17], a n d t h e i m p l e m e n t a t i o n o f t h e g o v e r n m e n t - f u n d e d M S S , w h i c h focuses o n P H C facilities i n rural areas, a r e w e l c o m e initiatives t o help reverse t h e c u r r e n t inequities in service p r o v i s i o n across Nigeria. Adequate p r o v i s i o n o f resources at P H C facilities is, therefore, required t o e n s u r e t h e p r e v e n t i o n a n d treatment of w o m e n with complications of pregnancy and, ultimately, t o reduce m a t e r n a l a n d n e o n a t a l m o r t a l i t y rates. Conducting this type o f survey often comes w i t h its limitations. T h e P H C facilities w e r e selected t ob e part o f t h e M S S u s i n g a set o f c r i t e r i a t h a t e m p h a s i z e d r u r a l l o c a t i o n . H e n c e , t h e findings o f t h e

present s t u d y reflect w h a t generally occurs i n t h e rural P H C facilities. S o m e o f t h e data w e r e collected f r o m t h e M N C H registers at t h e P H C facilities, w h i c h is s o m e t i m e s p o o r l y recorded a n d i n c o m p l e t e . H o w ever, t h e s t u d y covered a large n u m b e r o f P H C facilities f r o m across t h e 3 6 s t a t e s a n d F C T o f N i g e r i a . A s a r e s u l t , t h e findings a r e r e l e v a n t to t h e efforts i n strengthening t h e healthcare system i n Nigeria today, particularly at t h e P H C level i n rural communities. The present study provides useful information o n t h e statuso f prenatal care a n d B E m O C services i n rural Nigeria. T h e M S S facilities are already being upgraded t o meet t h e standards required f o r BEmOC using information uncovered b y t h e present survey. A concerted effort is n e e d e d b y a l l levels o f t h e G o v e r n m e n t o f Nigeria, as w e l l a sits D e v e l o p m e n t Partners, t op r o v i d e resources a tt h e P H C level that ensure all facilities a r e well-equipped t o keep pregnant w o m e n alive i n t h e r u r a l areas. T h e N a t i o n a l H e a l t h Bill, w h i c h h a s just been passed b y t h e Nigerian Legislators w i t h t h e provision for a P r i m a r y Health Care Development Fund, w o u l d go a long w a y t o support t h e strengthening o f t h e P H C system i n Nigeria [18].

Acknowledgments T h e National P r i m a r y Health Care D e v e l o p m e n t Agency o f Nigeria sponsored the present study. Conflict of interest T h e authors have n o conflicts o f interest

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