USE PATTERN OF MATERNAL HEALTH SERVICES AND DETERMINANTS OF SKILLED CARE DURING DELIVERY IN NIGERIA:
Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health.
Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.
It is almost two decades now since the initiation of the Safe Motherhood Initiative, but maternal mortality is still soaring high in most of the developing countries. In the year 2000, WHO estimated maternal mortality ratio of 920/100000 live births for Sub-Saharan Africa with a lifetime risk of a maternal death of 1 in 16. These rates are very high when compared to the developed countries lifetime risk of 1 in 2800 estimated during the same time period .
Reports show that more than three quarters of maternal deaths are due to direct obstetric causes such as haemorrhage, abortion, sepsis, ruptured uterus and hypertensive diseases of pregnancy . Most of these maternal deaths can be averted because the technical and political means to prevent them have been available for many decades. For example, it is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality and morbidity [3, 4, 5, 6]. In the technical consultation held ten years of Safe motherhood initiative it was clearly stated that: “Having a health worker with midwifery skills present at child birth, backed up with transport in case of emergency referral is perhaps the most critical intervention for making motherhood safe” . Due to this fact, the proportion of births attended by skilled health personnel is used as one of the important indicators to monitor progress towards the achievement of the millennium development goal of reducing maternal mortality ratios. The targets set at the International Conference on Population and Development+5 (ICPD+) is to have more than 80% of deliveries assisted by skilled attendants globally by 2005, 85% by 2010 and 90% by 2015 .
In Tanzania, like other Sub Saharan Africa countries, maternal mortality remains to be a problem of public health importance. The 2004 Tanzania Demographic and Health Survey (TDHS) published a maternal mortality ratio (MMR) of 578/100000 live births  but other community based studies found MMR as high as 990/100000 live births in some districts . The life time risk of a maternal death in Tanzania has been estimated at 1 in 38 . Tanzania was ranked 6th among the 13 countries with highest levels of maternal mortality which account for 67% of all world maternal deaths .
Use of health facilities for delivery is still very low in Tanzania. It is reported that only 47% of deliveries occur in the health facilities and the remaining more than half deliver at home assisted by unskilled attendants . This is happening amidst the fact that Tanzania has a good network of health facilities with about 72% of the population residing within 5 km and 90% reside within 10 km of a health facility. Also maternal health care services are provided free of charge in almost all public facilities.
The objective of this study was to assess the use determinants of skilled attendants at delivery in Mtwara rural district. The information obtained will help the district health management team to develop interventions to improve use of delivery care services and ultimately achieve the millennium goal to reduce the high rates of maternal mortality.
The study was a cross sectional study. Quantitative research methods were employed in the study which involved interviews to a random sample of women (age 14–50) who gave birth within one year prior to the survey using a structured questionnaire. The questionnaire was pre-tested in a similar population in a neighbouring district to test for clarity, validity and reliability of the questions after which the tool was revised accordingly and finalised for use.
The study was conducted in the Mtwara rural district. Mtwara rural, one of the five districts that make up Mtwara region is located in the South Eastern corner of Tanzania. The district has a total population of 204,770  and has a total of 34 health facilities, 4 being health centres and 30 being dispensaries. Normally at the dispensary the staff should include a clinical officer (Certificate holder in clinical medicine) and a Maternal and Child Health Aid (MCHA) while in the health centre there should be a Clinical Officer and 2 nurse midwives. Both health centres and dispensaries are supposed to provide basic emergency obstetric care services but sometimes not all the six core functions are available. The district has no hospital but the regional hospital (Ligula) serves as the first referral level for emergency obstetric care for this district where emergency obstetric care services are provided for 24 hrs. Few villages are located more than 80 km from the regional hospital but the majority of the populations is within 60 kilometres. The district has one ambulance stationed at the district headquarters and all health centres and 5 distant dispensaries were fitted with radio calls for communication in case of an emergency. The dispensaries in the district were recently provided with what are locally called cycle ambulances (bicycles fitted with locally made stretcher). During an emergency, relatives pick the cycle from the dispensary and use it to transport the patient to the dispensary or even to the hospital. Both the ambulance and the cycle ambulances are used free of charge. The district has a high maternal mortality ratio estimated at 600 per 100,000 live births and only a small proportion of women use of modern contraceptives (25%).
Sampling and Sample size
This study was conducted as a baseline survey of an intervention study aimed at increasing skilled attendance during delivery and increasing referral compliance. A multistage cluster random sampling was employed to select the study sample. We first selected a random sample of 24 health facilities using simple random sampling technique. For each of the selected health facility, one village in its catchment area was selected randomly. In the selected village, a house to house survey was conducted and all women who had given birth within the previous one year were interviewed.
Data entry and cleaning was done using EPI Info 6.04d program while data analysis was done using SPSS for Windows Version 11. A composite socio-economic status indicator (wealth index) was created using information on source of drinking water, type of toilet facilities, housing construction material, household assets, ownership of any form of transportation, ownership of animals, land ownership and source of family income. Data Reduction using the principle components and factor analysis was used to generate weighted scores from the above variables and normalized with a mean of zero and standard deviation of one. The resulting scores were then summed up within households, ranked and used to stratify the households into 5 levels of socio-economic status.
A variable, knowledge of pregnancy danger signs, was arrived at but analyzing the number of danger signs the respondent mentioned spontaneously. Those who mentioned none were considered to have no knowledge, those respondents who mentioned up to three danger signs were considered to have low knowledge and those who mentioned 4 or more danger signs were considered to have moderate knowledge of pregnancy danger signs. None of the respondents was considered to have a high knowledge as none mentioned more than 8 out of a total of 17 risk factors printed on the antenatal card.
The χ2 test was used to assess association between use of maternal health care services and socio-demographic variables, and other service characteristics. P-values of less than 0.05 were considered significant.
Multiple logistic regression was used to assess individual effect of variables on use of skilled care attendance while adjusting for potential confounding variables.