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International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
23
Socio-economic Predictors of Maternal Healthcare Uptake by Women in Makoko Community, Lagos,
Nigeria
Idongesit Eshiet (Ph. D)
Department of Sociology, University of Lagos, Lagos, Nigeria. E-mail: doshiet2@yahoo.com
Abstract
The study investigated the socio-economic predictors of maternal healthcare uptake in Makoko community (an urban
slum) within the Lagos metropolis, Nigeria. A cross sectional survey was conducted on a sample size of 250 women of
child bearing age (15 – 49 years), randomly drawn from the community, using the multi-stage sampling technique.
Specifically, the study sought to unravel if age, marital status, education, employment status, income, birth order,
husband’s education and distance to health facility mediated on the uptake of maternal healthcare by women in Makoko
community. Conflict and symbolic interactionism perspectives serve as the theoretical underpinnings of the study.
Findings reveal that age, education, income, birth parity and husband’s education are positively correlated with the uptake
of maternal healthcare. The study recommends targeted campaigns by government and non-governmental organizations
on the dangers of lack of maternal healthcare, skill training for unemployed women and improvement of health facilities
in Makoko community.
Key words: antenatal, safe delivery, postnatal, family planning, mortality, death
Introduction
Maternal healthcare refers to pregnancy related care. It is
healthcare provided for women, especially during
pregnancy, childbirth and the postpartum period in order to
prevent maternal morbidity and mortality (WHO, 2012a).
Maternal morbidity and mortality have remained an
endemic health issue for women through the ages. Globally,
maternal deaths stand at 216 deaths per 100,000 live births
with the approximate lifetime risk of maternal death being
1 in 180 (WHO, 2015). However, the burden of maternal
deaths is unevenly shared between the developed and
developing worlds. While the developed world has been
freed from the shackles of maternal deaths, the developing
world is still grappling with the challenge. A majority of
the deaths still occurs in the developing world. The
developing world currently accounts for about 99%
(302,000) of maternal deaths and has a maternal mortality
ratio of 239. This is 20 times higher than the 12 deaths per
100,000 live births in the developed world. Similarly, the
estimated lifetime risk of maternal death in the developed
world is 1 in 3,300, as compared to 1 in 41in the developing
world (WHO, 2015). Regionally, sub-Saharan Africa has
the highest maternal mortality ratio. It accounts for about
66% (201,000) with a maternal mortality ratio of 546.
Equally, a woman's life time risk of dying during or
following a pregnancy is estimated at 1 in 36 in sub-Saharan
Africa as compared to 1 in 4,900 for the developed world
(WHO, 2015). At the country level, Nigeria and India
account for over one third of all maternal deaths globally.
Nigeria accounts for 19% (58,000) with a maternal
mortality ratio of 814, while India accounts for 15%
(45,000) of the deaths (WHO, 2015).
The World Health Organization says these deaths are
needless, as there are health-care solutions to prevent or
manage maternal health issues (WHO, 2012a). In view of
this, the United Nations, through its Development Goals
has taken steps to curtail maternal deaths. Hence, both
Millennium Development Goal (MDG) 5 and Target 3.1 of
Sustainable Development Goal (SDG) 3 focus on reducing
the global maternal deaths. Specifically, MDG 5 aimed at
reducing maternal mortality ratio by three-quarters between
1990 and 2015 (UN, 2005) while Target 3.1 of SDG 3 aims
at reducing maternal mortality ratio to less than 70 per
100,000 live births by 2030 (UN, 2016). These goals have
Eshiet, I. (2018) Article Received May 2018, Published June 2018. Website: https://ediomsric.com/international-journal-of-integrativehumanism/
© Faculty of Arts, University of Cape Coast, Ghana and Faculty of Arts, University of Calabar, Nigeria. Email: jihumanism@ediomsric.com
International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
24
encouraged national governments to take actions to stem
maternal deaths. These have resulted in a reduction in
maternal deaths however, the achievements still remain a
far cry from the targets of the goals. A majority of women
in the developing world still lack access to maternal
healthcare. Poor women in the rural areas and urban slum
settlements are particularly vulnerable, as their access and
uptake of maternal healthcare is marred by political, socio-
economic, and demographic factors among others. This
study therefore, aims at investigating the socio-economic
predictors of maternal healthcare uptake in Makoko
community (an urban slum) in the Lagos metropolis,
Nigeria.
Statement of Problem
Nigeria ranks as the second contributor to maternal deaths
globally, accounting for 19% (58,000) of the overall deaths
and having a maternal mortality ratio of 814 deaths per
100,000 live births (WHO, 2015). This fact though
alarming is however, not surprising due to the revelations
of the National Demographic and Health Survey. The
National Demographic and Health Survey (NDHS) 2013,
findings reveal a gloomy picture about the maternal health
situation in Nigeria. The survey reveals that contraceptive
usage by married women stands at 15%. The aftermath of
this is Nigeria’s high fertility rate, which stands at 5.5
children per woman. However, despite this high fertility
rate, access and uptake of maternal healthcare is limited.
The survey reveals that only 38% of births are delivered by
a skilled health provider (midwife, doctor or nurse), while
only 36% of them are delivered in a health facility. On the
other hand, only 51% of mothers receive at least four
antenatal care visits during pregnancy, while equally, only
40% of them receive a postnatal check-up within the first
two days of giving birth (National Population Commission
& ICF International, 2014). Similarly, UNICEF (2013)
observes that less than 20 per cent of health facilities in the
country offer emergency obstetric care.
In response to the then MDG Goal 5 and now SDG Target
3.1 of Goal 3, the Nigerian government like other national
governments has taken steps to curb maternal deaths.
Among such steps is the adoption of the UNICEF/WHO
Integrated Management of Newborn, Infant, and Childhood
Health (IMNCH) strategy, which was designed to fast-track
the achievement of MDG Goals 4 and 5. The strategy is an
all-encompassing evidence-based approach, which
incorporates all aspects of maternal and child healthcare
system, including material and human resources, health
governance, health information, strengthening of clinical
services and community engagement (Findley et al, 2013).
The strategy was adopted in 2007, under the auspices of the
Federal Ministry of Health (Federal Ministry of Health,
2007).
Despite this intervention, much progress has not been
achieved in tackling maternal deaths. Nigeria still ranks as
one of the countries with the highest maternal mortality
ratio globally with a mortality ratio of 814 deaths per
100,000 live births. Part of the reason adduced for this is
due to the lack of access of a majority of women to maternal
healthcare. Access may be limited by a myriad of factors,
which include cultural, political, religious, socio-economic,
demographic and geographical. This calls for micro level
studies such as the intended study to unravel some of the
factors that mediate access and uptake of maternal
healthcare by women.
This study therefore, aims at investigating the socio-
economic predictors of maternal healthcare uptake in
Makoko community in the Lagos metropolis. Specifically,
the study aims at unraveling the relationship between age,
marital status, education, employment status, income, birth
order, husband’s education and distance to health facility
and uptake of maternal healthcare in Makoko community.
Theoretical Frameworks
The analysis of the socio-economic predictors of the uptake
of maternal healthcare in Makoko community is situated
within an eclectic theoretical approach namely the
sociological conflict and symbolic interactionism
perspectives.
The conflict perspective pioneered by the classic works of
Karl Marx explains the structuring of society from the
viewpoint of historical materialism. It argues that at all
times, human society is structured into two classes – the
dominant and the dominated. In the capitalist society, the
dominant class comprises the ruling class and the owners of
the means of production, who use their power to make
policies that protect its class interest (Haralambos and
Heald, 2008). From this viewpoint, urban slums are
manifestations of the lopsided policies, of the ruling class.
The urban fringes become haven to the less privileged who
have no access to housing in the planned areas. Hence urban
slums are dirty, overcrowded and lack basic amenities
International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
25
including healthcare facilities, and this limits the access of
women to maternal healthcare.
The symbolic interactionism perspective is concerned with
the social psychological dynamics of individuals
interacting in small groups. The perspective has its origins
in the works of George Simmel, Charles Cooley, George
Herbert Mead and Erving Goffman (Haralambos and
Heald, 2008). From the symbolic interactionism
perspective, the social world could be explained from the
basis of the social interactions that occur between
individuals and the meanings derived from such
interactions by the individuals. Thus, the meanings that
individuals give to their interactions with one another and
to the symbols within their socio-cultural environment,
affect their response to such symbols. For example, the
meanings that people give to orthodox healthcare vis-à-vis
unorthodox care affects their response to either healthcare
system. Where the meaning given to orthodox healthcare
is positive, people will make use of the facilities but if it is
negative, they will not make use of it. In urban slums, where
there is high level of poverty and low level of literacy, much
importance may not be attached to maternal healthcare.
Thus, child bearing women may not subscribe to maternal
healthcare even where such healthcare services are
available within the community. They may still prefer
unorthodox maternal care such as drinking herbs, visit to
traditional birth attendants, etc. This is attributed to the
positive meaning they attach to such practices.
Dimensions of Maternal Healthcare
Maternal healthcare seemingly a unified system of
healthcare nevertheless, has different components. The
World Health Organization (WHO, 2012a) outlines the
components of maternal healthcare as encompassing family
planning, preconception, prenatal, delivery and postnatal
care.
Family Planning – refers to a conscious effort by a couple
to limit their family size or space their children using
contraceptives. The World Health Organization (2012b)
observes that prevention of unwanted and too-early
pregnancies is vital to tackling maternal deaths. The
organization argues that satisfying the unmet need for
family planning of women alone could reduce the number
of maternal deaths by almost a third (WHO, 2012b). Yet,
WHO observes that globally, over 10% of women do not
have access to or are not using an effective method of
contraception. Thus, it advocates that all women including
adolescents should be given access to family planning
(WHO, 2012a). In Nigeria, the National Demographic and
Health Survey (2013) data reveals that only 15% of married
women use a contraceptive method, while 16 per cent has
an unmet need for family planning services. On the overall,
contraceptive prevalence among women in Nigeria is 16
per cent (National Population Commission & ICF
International, 2014).
Antenatal Care (ANC) - refers to the medical care of a
woman during pregnancy. The major objective of antenatal
care is to ensure optimal health outcomes for the mother
and child. Antenatal care from a trained healthcare provider
helps to monitor the pregnancy and reduce morbidity risks
for mother and child during pregnancy and delivery. It has
been observed that ANC provides the following benefits for
mother and child – (a) it enables early detection of
complications and prompt treatment (for example,
detection and treatment of sexually transmitted infections),
(b) it enables the prevention of diseases through
immunization and micronutrient supplementation, (c) it
enables birth preparedness and complication readiness and
(d) it enables health promotion and disease prevention
through health messages and counseling (National
Population Commission & ICF International, 2014:128).
The World Health Organization recommends a minimum
of four ANC visits for every pregnant woman who has no
complications. The first visit should occur by the end of 16
weeks of pregnancy, the second visit should be between 24
and 28 weeks of pregnancy, while the third visit should be
by 32 weeks and the fourth visit by 36 weeks. However,
women with complications, special needs or conditions
beyond the scope of basic care may require additional visits
(National Population Commission & ICF International,
2014). Nigeria’s ANC policy aligns with the WHO’s
approach. However, statistic reveals that only 51 per cent
of pregnant women in Nigeria have four antenatal visits
while 34 per cent do not have antennal care (National
Population Commission & ICF International, 2014).
Delivery Care – entails delivery in a health facilityandby a
skilled attendant – skilled attendance at delivery
encompasses the presence of health professionals such as
doctors, midwives, and nurses as well as an enabling
environment, where the equipment, drugs and other
resources required for effective and efficient management
of complications are available. Evidence from the
developed world shows that delivery in health facility and
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by a skilled attendant are the major factors that have led to
the drastic reduction in maternal deaths (Adamu, 2011;
Kruk et al, 2007). In Nigeria, only 36 per cent of births are
delivered in health facilities, while 63 percent are delivered
at home (National Population Commission & ICF
International, 2014).
Postnatal Care (PNC) – The postnatal period is the time
from immediately after birth up to 40 days. The postpartum
period is particularly important for women, because during
this period, they may develop serious life-threatening
complications, especially in the interval immediately after
delivery. Evidence shows that a large proportion of
maternal and neonatal deaths occur during the first 48 hours
after delivery (National Population Commission & ICF
International, 2014; Adamu, 2011). Thus, receiving
postnatal care is critical in making a difference between life
and death for mother and child. It prevents death from
preventable causes such as hemorrhage, infections and
hypertensive disorders, which are common diseases during
this period (WHO, 2012a).
Postnatal care visits also provide opportunity to learn and
acquire information on issues such as family planning,
maternal and child nutrition, immunization, hygiene and
sanitation, etc. (USAID, 2009). WHO recommends that all
women receive a health check within two days of giving
birth. But statistic show that 58 percent of women in
Nigeria do not have postnatal checkup (National Population
Commission & ICF International, 2014).
Barriers to Maternal Healthcare in Developing
Countries
There is a great disparity in the healthcare systems of the
developed and developing world. While the developed
world has a viable healthcare and referral system in which
pregnant women can receive emergency obstetric care
when needed, this is absent in the developing world
(Adamu, 2011). However, apart from the lack of a viable
healthcare and referral system, evidence from studies reveal
some other socio-economic, demographic, cultural and
geographical factors that mediate access to maternal
healthcare in developing countries. For example, studies
reveal mother’s age at child birth as influencing access and
utilization of maternal healthcare, although there are
contradictory findings with regard to the direction of the
effect of mother’s age and utilization of maternal healthcare
services. While some studies show a lack of association
between mother’s age and utilization of maternal healthcare
services (Magadiet al, 2007; Celik& Hotchkiss, 2000),
some others show higher utilization for younger women
than older women (Abou-Zahr&Wardlaw, 2001), yet some
others show a higher utilization for older women than
younger women (Tsaweet al, 2015; Reynolds et al, 2006).
Similarly, parity or birth order is shown as a predictor of
maternal healthcare services utilization. Evidence shows
that women who have more than three living children are
more confident about their ability to handle their maternal
health issues and so do utilize maternal health services less
frequently than those who have had less than three children
(Tsaweet al, 2015; Raj Baralet al, 2012; Simkhadaet al,
2008).
Maternal education is also shown as a factor influencing
access and utilization of maternal healthcare services.
Studies reveal that the higher a woman’s level of education,
the more likely she is to access and use maternal healthcare
services (Tsaweet al, 2015; Ononokpono&Odimegwu,
2014: Ayeleet al, 2014). However, some other studies do
question the independent effect of education on maternal
health utilization, arguing that some other factors such as
husband’s educational level, socio-economic environment
do mediate on the association between education and
utilization of maternal healthcare services (Gage &Calixte,
2006; Raghupathy, 1996).
Studies similarly show a relationship between women’s
employment status and access to and utilization of maternal
healthcare services. While it could be assumed that
working women who earn income would have more
autonomy and the financial wherewithal to seek maternal
healthcare services, in reality this is not always so, as the
context in which women are employed does impact on their
access to maternal healthcare services. Thus, the contextual
differences in women’s employment have given rise to
different findings on the association between employment
and access to and utilization of maternal health services.
Studies reveal a positive relationship between a woman’s
formal employment and utilization of maternal healthcare
services as such healthcare provisioning are part of the
official employment benefits (Ononokpono&Odimegwu,
2014; Dalalet al, 2012), however, in context where women
have no control over their earnings and where women do
not earn money for the work they do or where employment
is poverty-induced, employment is found not to be
International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
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associated with maternal healthcare services utilization
(Lowe et al, 2016; Furuta&Salway, 2006; Addai, 2000;
Nwakoby 1994).
The place of residence similarly plays a significant role in
access to and utilization of maternal healthcare services.
Studies show that women who reside in urban areas are
more likely to have access to and utilize maternal healthcare
services than those who reside in the rural areas
(Muchabaiwaet al, 2012; Dagne, 2010; Babalola &Fatusi,
2009). This may be attributed to the lopsided healthcare
provisioning in developing countries in which sophisticated
health facilities are often situated in the urban areas
(Peltzeret al, 2005). Thus, issues of accessibility and
affordability have been critical factors in determining
maternal healthcare utilization as rural women often have
to travel long distances before accessing the nearest heath
facility (Tsawe&Susuman, 2014; Silalet al, 2012; Ensor &
Cooper, 2004).
Household wealth quintile is also associated with the use of
maternal healthcare services. This is however, not
surprising, as the use of maternal healthcare services entails
some monetary costs such as cost of transportation,
medication, user fees, etc. Thus, women from rich families
are more likely to utilize maternal healthcare services than
women from poor families (Gabrysh& Campbell, 2009).
Likewise, the use of maternal healthcare also increases with
the wealth quintile of women themselves, thus women from
the rich quintile use maternal healthcare services more than
those from the poor quintile (Fotsoet al, 2009).
Religion also mediates access to and utilization of maternal
healthcare services. For example, studies reveal a higher
use of maternal healthcare services by non-Muslim women,
and a lower rate of use by Muslim women
(Babalola&Fatusi, 2009; Ethiopian Society of Population
Studies, 2008; Addai, 2000). Similarly, cultural factors
such as the traditional gender division of labour, patriarchy,
which denies women autonomy in decision making, etc. are
associated with non-utilization of maternal healthcare
services (Lowe et al, 2016; Ayeleet al, 2014).
The factors that mediate on women’s access to maternal
healthcare services are complex, numerous and varied,
hence this review is not exhaustive, as it has only discussed
some of the variables.
Methods
Research Design and Setting – The study utilized a cross
sectional survey to gather quantitative data from Makoko
community, an urban slum settlement within the Lagos
metropolis of Nigeria. Makoko is a multi-ethnic fishing
community with a population size of 85,840 comprising of
43,280 males and 41,540 females. A third of the community
is built on stilts along the lagoon and the rest on land.
Makoko is made up of six distinct ‘communities’ spread
across land and water - OkoAgbon, Adogbo, Migbewhe,
Yanshiwhe, Sogunro and Apollo. The first four are the
floating communities, known as ‘Makoko on water’ while
the rest are based on land. Makoko has a non-functional
government primary health centre located within the
community. However, there is a network of privately
owned hospitals and some informal, unregistered clinics
that attend to the health needs of the community. There are
also a number of traditional birth attendants (Ogunlesi,
2016).
Study population – The study population comprised of
child bearing women (15-49 years) who were single and
never married and those who have been ever married and
who gave at least one live birth in the five years prior to the
time of the survey and were resident in the community.
Sample Size and Technique – A sample size of 250
women was drawn using the multi-stage sampling
technique. Makoko comprises of 6 communities -
OkoAgbon, Adogbo, Migbewhe, Yanshiwhe, Sogunro and
Apollo. Four of the communities are floating communities
on water, while two are on land. The two communities on
land - Sogunro and Apollo, were purposively selected for
the study to allow for convenience of gathering the data.
Twenty-four streets were identified in the two communities
and houses on the streets were enlisted. Respondents were
randomly selected from the enlisted houses.
Data Collection- Quantitative data was gathered using the
questionnaire. Questions were asked on socio-demographic
characteristics of respondents, access to and uptake of
family planning; antenatal care; delivery care and postnatal
care. In collecting the data, a face-to-face interview
technique was used.
Ethical considerations - such as anonymity,
confidentiality, as well as informed consent were obtained
from respondents.
International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
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Data Analysis - The Statistical Package for Social Sciences
(SPSS) version 20 was used to analyze the data. Findings
are presented in descriptive and inferential statistics. The
independent variables are age, marital status, education,
employment status, income, birth order, husband’s
education and distance to health facility while maternal
healthcare is measured by - antenatal care (ANC)
(compliance with WHO prescribed minimum of four ANC
visits); delivery care (delivery in a health facility and by a
skilled attendant); and postnatal care (PNC) (received from
a skilled medical professional within two days of delivery).
Results
The results are analyzed and presented in descriptive and
inferential statistics. Findings are discussed under the
various dimensions of maternal healthcare – family
planning, antenatal care, delivery care and postnatal care.
Uptake of Family Planning by Women in Makoko
Community
Variables that measure the reproductive health practices of
respondents were analyzed using descriptive statistics and
presented in simple frequency and percentage distributions.
Findings reveal that 21.2% of the respondents have had one
or more abortions. Similarly, 58.0% do practice family
planning. For those who practice family planning, 90.3%
practice modern family planning, with a majority of them
using condom. However, 9.7% practice traditional type of
family planning such as withdrawal method, the use of
herbs, and other unconventional substances such as
alcoholic drink, lime, salt, etc. Similarly, 66.2% of those
who practice family planning had the onset of their first
family planning after their first life birth. And about 14.0%
of them obtained the family planning services in a
government hospital, while 10.0% did so in a private
hospital. However, 84.0% do so through diverse sources,
such as chemists, herbs, condoms, withdrawal, etc.
Socio-economic Predictors of uptake of Maternal
Healthcare by Women in Makoko Community
Table 1 is a summary of the chi square test of the socio-
economic variables that mediate on the uptake of maternal
healthcare (antennal care, delivery care and postnatal care)
in Makoko community.
Table 1: Socio-economic Predictors of uptake of Maternal Healthcare by Women in Makoko Community
Variable Four ANC Visits Delivery in Health Facility Postnatal Care (ANC)
X2 P-Value X2 P-Value X2 P-Value
Age 21.372 .0000 3.122 0.210 5.579 .061
Marital Status 2.248 .134 4.083 .043 4.859 .027
Education 3.806 .283 10.376 0.016 14.385 .002
Employment Status .008 .929 7.615 .006 17.401 .000
Income 8.192 .017 14.336 .001 7.362 .025
Birth Order 23.612 .000 4.621 .202 3.232 .357
Husband’s Education .902 .637 6.793 .033 19.881 .000
Distance to Health Facility .249 .618 .087 .768 .792 .374
Uptake of Antenatal Care (ANC) by Women in Makoko
Community
The descriptive analysis of uptake of ANC reveals a high
level of utilization. About 92.2% of respondents admit to
having had at least four ANC visits in their last pregnancy.
However, the inferential statistics based on chi square test
(see Table 1) reveals no association between marital status
(X2 = 2.248, df=1, P>.05); education (X2 = 3.806;df =3,
P>.05); employment status (X2 = .008, df= 1, P>.05);
husband’s education (X2 = .902, df= 2, P>.05); and distance
to health facility (X2 = .249, df= 1, P>.05) and uptake of
ANC. On the other hand, age (X2 = 21.372, df=2, P<.05);
income (X2 = 8.192, df =2, P<.05); and birth order (X2 =
23.612, df=3, P<.05) are associated with uptake of ANC.
In terms of age, younger women less than 30 years are more
likely to utilize ANC. However, uptake tends to decline
with age as women; ages 30-39 years also utilize ANC more
than those who are 40 – 49 years. With regards to birth
order, uptake is higher for women who have given birth to
less than three children and less with those who have given
birth to three children and above. Hence, parity is
significant with uptake. The lack of association between
distance to health facility as established in some other
International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
29
studies (Muchabaiwaet al, 2012; Dagne, 2010;
Babalola&Fatusi, 2009) may be attributed to the fact that
the gap between the nearest and farthest distance is not
much. The farthest distance to a health facility is more than
1 Km (21.6%) while the nearest is less than 1 Km (78.4%).
The variables associated with ANC uptake (age, income
and birth order) are further subjected to multivariate
analysis using the logistic regression model as depicted in
Table 2.
Table 2: Logistic Regression Model for uptake of ANC by Women in Makoko Community
Variable B S.E. Exp(B) 95% C.I.for EXP(B)
Age Lower Upper
< 30 years (Ref)
30 – 39 years -1.040 .426 .353** .153 .815
40 – 49 years -1.033 .716 .356 .087 1.448
Income
N1 – N10,000 (Ref)
N10,001 – N20,000 .967 .445 2.629* 1.098 6.294
N20,001 & above 1.832 .795 6.247* 1.315 29.672
Birth Order
1 (Ref)
2 -.724 .512 .485 .178 1.322
3 -.729 .589 .482 .152 1.529
4 & above -1.458 .628 .233* .068 .798
*p<0.5; **p<0.01; *** <0.001
Result of logistic regression as depicted in Table 2 further
confirms that age, income and birth order are predictors of
uptake of ANC. In terms of age, women between ages 30
– 39 years are less likely to uptake ANC than women who
are less than 30 years. This means that uptake declines with
age. With regards to income, uptake increases in the same
direction with income. Thus, women with higher incomes
(N10,001- N 20,000) are two times more likely to uptake
ANC than those with less (below N10,000) incomes.
Similarly, those with incomes that are higher than N20,001
and above are six times more likely to uptake than those
with less (N10,000 and below) incomes. Uptake similarly
declines with birth order. Women who have at least three
and above live births are less likely to comply than those
who have less than three live births.
Uptake of Delivery Care by Women in Makoko
Community
Result of the chi square test in Table 1 reveals no
association between age (X2 = 3.122, df=2, P>.05); birth
order (X2 = 4.621, df=3, P>.05); and distance to health
facility (X2 = .087, df=1, P>.05) with delivery care.
However, marital status (X2 = 4.083, df=1, P<.05);
education (X2 =10.376, df=3, P<.05); employment status
(X2 =7.615, df=1, P<.05); income (X2 =14.336, df=2,
P<.05); and husband’s education (X2 = 6.793, df=2,
P<.05) are associated with delivery care. In terms of marital
status, the result reveals that married women are more likely
to have delivery care than single women, while employed
women are more likely to have delivery care than the
unemployed. Similarly, women who earn higher income are
more likely to have delivery care than those who earn less.
Also, women whose husbands have a higher education are
more likely to have delivery care than those with lower or
no education.
The variables associated with delivery care (education,
employment status, income and husband’s education) are
further subjected to a multivariate logistic regression
analysis to see if they would be predictors of delivery care
as depicted in Table 3.
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Table 3: Logistic Regression Model for uptake of Delivery Care by Women in Makoko Community
Variable B S.E. Exp(B) 95% C.I.for EXP(B)
Level of Education
None (Ref)
Primary -1.734 1.096 .177 .021 1.513
Secondary -1.167 1.111 .311 .035 2.744
Tertiary -1.225 1.364 .294 .020 4.257
Employment Status
Unemployed/housewife (Ref)
Employed -.142 .661 .868 .238 3.170
Income
N1 – N10,000 (Ref)
N10,001 – N20,000 1.199 .497 3.318** 1.254 8.781
N20,000 & above 1.050 .807 2.859 .588 13.891
Husband’s Education
Primary (Ref)
Secondary .524 .482 1.688 .657 4.338
Tertiary .921 .834 2.511 .490 12.866
*p<0.5; **p<0.01; *** <0.001
Result in Table 3 reveals that marital status, education,
employment status and husband’s education are not
predictors of uptake of delivery care. However, income is a
predictor of delivery care. Women who earn income,
between N10,001 – N20,000 are three times more likely to
uptake delivery care than those who earn N10,000 and less.
Uptake of Postnatal Care (PNC) by Women in Makoko
Community
Result of the descriptive statistic reveals a high uptake of
postnatal care (83.6%). However, result of the chi square
test in Table 1 reveals that age (X2 = 5.579, df=2, P>.05);
birth order (X2 = 3.232, df=3, P>.05); and distance to health
facility (X2 = .792, df=1, P>.05) are not associated with
uptake of PNC. However, marital status (X2 = 4.859, df=1,
P<.05); education (X2 = 14.385, df=3, P<.05); employment
status (X2 = 17.401, df=1, P<.05); income (X2 = 7.362,
df=2, P<.05); and husband’s education (X2 = 19.881, df=2,
P<.05) are associated with postnatal care.
The variables associated with uptake of postnatal care
(marital status, education, employment status, income and
husband’s education) are further subjected to a multivariate
analysis as depicted in Table 4.
Table 4: Logistic Regression Model for uptake of Postnatal Care by Women in Makoko Community
Variable B S.E. Exp(B) 95% C.I.for EXP(B)
Education
None (Ref)
Primary -.730 .885 .482 .085 2.730
Secondary -.032 .940 .968 .153 6.118
Tertiary -.602 1.201 .548 .052 5.768
Employment Status
Unemployed/housewife (Ref)
Employed .705 .663 2.023 .551 7.425
Income
N1 – N10,000 (Ref)
N10,001 – N20,000 .689 .617 1.992 .595 6.670
N20,001 & above -.312 .742 .732 .171 3.136
Husband’s Education
Primary (Ref)
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31
Secondary 1.476 .551 4.374** 1.486 12.878
Tertiary 1.199 .900 3.317 .569 19.355
*p<0.5; **p<0.01; *** <0.001
Result of logistics regression in Table 4 reveals that marital
status, education, employment status and income are not
predictors of uptake of postnatal care; however, husband’s
education is a predictor of uptake of postnatal care. Women,
whose husbands have a secondary education, are four times
more likely to have postnatal care than those with no or
primary education.
Discussion
This study investigated the socio-economic predictors of
uptake of maternal healthcare by women in Makoko
community, an urban slum within the Lagos metropolis of
Nigeria, using a cross sectional survey of 250 women of
child bearing age (15 -49 years), who gave at least one live
birth in the five years prior to the time of the survey. The
study sought to unravel the mediating influence of age,
marital status, education, employment status, income, birth
order, husband’s education and distance to health facility
on the uptake of maternal healthcare.
Descriptive and inferential statistics were utilized to
analyze the quantitative data. Result of the descriptive
statistics reveal an average level of uptake of family
planning (58.0%); a high level of uptake of antenatal care
(92.4%); delivery care (78.8%); and postnatal care (83.6%).
These statistics are higher than those of the national
average, which shows a contraceptive prevalence of 16 per
cent; 51% antenatal care; 38% of delivery care; and 40 %
of postnatal care.
Result of the bivariate analyses reveals that age, marital
status, education, employment status, income, birth order,
and husband’s education are associated with uptake of
maternal healthcare by women in Makoko community. This
result aligns with the findings of other similar studies such
as Tsaweet al (2015); Ononokpono&Odimegwu (2014);
Ayeleet al (2014); Gage &Calixte (2006); Raghupathy
(1996); and Dalalet al (2012).
The multivariate analyses to investigate the association of
these variables with the different dimensions of maternal
healthcare reveals age, income and birth order as predictors
of uptake of antenatal care. Uptake of antenatal care
declines with age. Younger women are more likely to
utilize ANC than older women. Similarly, uptake of ANC
increases as income increases while it declines with more
live births. This result aligns with result of other studies
such as Ononokpono&Odimegwu, (2014); Ayeleet al
(2014); and Fotsoet al (2008). With regards to delivery
care, result indicates income as a predictor of delivery care.
Women with high income are three times more likely to
deliver in a health facility and by a skilled attendant than
those with lower income. This result is also in line with
Ononokpono&Odimegwu, (2014); Ayeleet al, (2014); and
Tsaweet al, 2015 findings. For postnatal care, result reveals
husband’s education as a predictor of postnatal care. This is
also in line with Ayeleet al (2014) and Dalalet al (2012)
findings.
The positive outcomes of this result should however, be
cautiously interpreted. This is because maternal healthcare
has standards as espoused by the World Health
Organization. Thus, maternal healthcare could either be
‘adequate’ or ‘inadequate’ if it fails to meet the WHO’s
standards. Therefore, in situations where efficient
healthcare delivery system is lacking, as it is often in urban
slum settlements, adequate or quality maternal healthcare
may be lacking. Makoko community has only one non-
functional government owned primary health center located
within the community. There is however, a network of
private hospitals and informal, unregistered health clinics
that attend to the health needs of the community. These
private hospitals and clinics lack the WHO standards to
provide ‘adequate’ or ‘quality’ maternal care for women,
especially delivery care. Quality delivery care encompasses
the presence of health professionals (doctors, midwives,
and nurses) as well as an enabling environment, where the
equipment, drugs and other resources required for effective
and efficient management of complications are available.
The health facilities in Makoko community lack the
capacity to offer emergency obstetric care as well as an
efficient referral system (although this was not part of the
investigation of this study). However, this assertion could
be supported by UNICEF (2013) report that less than 20 per
cent of health facilities in Nigeria offer emergency obstetric
care. From this vein, it could be argued that despite the high
uptake of maternal healthcare services by women in
Makoko community as revealed by this study, the reality is
that these women are as good as having no maternal care.
International Journal of Integrative Humanism Vol 9. No 1. June 2018. ISSN: 2026 – 6286
32
This is particularly so as 88.0% of respondents admitted
utilizing the health facilities within the community for their
maternal healthcare services. This observation corroborates
Fotsoet al (2009) study of access to maternal healthcare in
the slum settlements of Nairobi, Kenya, in which he raised
the rhetorical question ‘What does access to maternal
healthcare mean among the urban poor? Fotsoet al (2009)
study found that although 70% of their respondents
delivered in a health facility, only 48% of such deliveries
were attended to by a skilled attendant. Therefore, the result
of this study necessitates a further study to investigate the
‘quality’ of maternal healthcare services receive by women
in Makoko community.
Recommendations
• To make the maternal health seeking behaviour of
women in Makoko community to yield the desired
result, government should scale-up the health
facilities in Makoko community by ensuring
adherence of both government and privately-
owned facilities to the WHO standards of
operation. Defaulting private facilities should be
fined and sealed up until they comply.
• Government interventions should include a
focused on improved access to emergency obstetric
care as well as an efficient referral system.
• The reluctance of older women, as well as women
who have many live births to utilize ANC services
in Makoko community should be addressed
through targeted campaigns by government and
non-governmental organizations at such women,
on the dangers of non-utilization of ANC services.
• Since employment and income are predictors of
access to maternal healthcare, the government in
conjunction with non-governmental organizations
should empower poor unemployed women in
Makoko community through skill acquisition
trainings. Successful participants should be given
seed money to start off after the training.
• In view of the importance of husband’s education
in influencing uptake of maternal healthcare by
women in Makoko community, the family as a
cohesive unit should be the main target of maternal
healthcare interventions. Pregnancy should be
perceived as an inclusive event, where both
husband and wife should participate to ensure a
healthy outcome for both mother and child.
• Furthermore, the findings of this study are based on
the survey result of the part of Makoko community
‘on land’. Therefore, further study is required on
the part of Makoko community ‘on water’, to see if
the result will be comparable.
• In view of the very high maternal mortality ratio in
Nigeria, there is a need for more context specific
studies, in order to unravel the diverse variables
that mediate access and uptake of maternal
healthcare in diverse settings in Nigeria. This will
enable the adoption of appropriate policies to
address the problem.
Conclusion
Maternal mortality ratio has remained all-time high in
Nigeria over the years. Nigeria has consistently ranked as
the second highest contributor to maternal deaths globally.
This scenario makes maternal mortality to go beyond being
an individual problem to a societal problem, due to the
disruptive effect it has on the effective functioning of the
society. Despite Nigeria’s high fertility rate (5.5 children
per woman), the uptake of maternal healthcare services is
low. Contraceptive prevalence still stands at 16 per cent
while only 51% of women receive antenatal care, only 38%
delivery care and 40% postnatal care (National Population
Commission & ICF International, 2014). However,
contrary to the national picture, there is a high uptake of
maternal healthcare services by women in Makoko
community. Nevertheless, due to the poor quality of these
services, they may not be adequate to address causes of
maternal deaths. Thus, maternal healthcare uptake should
be accompanied by quality services to enable it stem
maternal deaths. In view of the findings of the study, the
following recommendations are made.
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