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Nigeria ranks among the nations with the highest mortality rates in the world going by the cur-rent maternal mortality ratio (MMR) of 630/100,000 live births. The utilisation of maternal health services is known to be associated with improved and maternal health outcomes among women. In order to encourage the use of health services by women in various communities, the most prominent communication approach used by midwives to reach out to women in Niger State is the group communication approach. For this reason, this study examines how effective the group communication campaign carried out by the Midwife Service Scheme (MSS) in Niger State is able to address the problem of child delivery at home among women in Niger State. The study adopts Mixed Methods Research to collect data from respondents. Cluster sampling and purposive sampling techniques were used to locate where the target population (pregnant women and nursing mothers) are concentrated (primary health centres) as well as those interviewed as key informants (MSS focal person, midwives and nurses). In addition, participant observation was used in order to detect some information that the respondents may be shy to talk about or may not want to divulge at all. Three hundred copies of questionnaires were administered to pregnant women and nursing mothers drawn from three primary health centres of the three local government areas selected through balloting within Niger State. The study discovered that the group communication campaign carried out by the MSS in Niger State is effective in addressing the problem of child delivery at home. It also discovered that women are better reached by mid-wives and nurses through face-to-face communication approach by assembling them in various primary health centres within communities of Niger State thereby promoting attendance and par-ticipation of the exercise. Also, the study found out that most women‘s decision to visit the hos-pital for childbirth was influenced by the communication campaign carried out by the MSS. In other words, the campaign has positively changed the views and perceptions of majority of the women within the study area who do not visit health centers for childbirth. Again, the study dis-covered that distance was the major factor affecting women‘s attendance for the campaign as well as their utilisation of maternal health services. Therefore, the study recommends that more PHCs should be established in different locations across each community so as to complement the existing ones which may go a long way in solving the problem of distance. Also, there should be systematic evaluation of the campaign carried out by the MSS as well as other health campaigns within Niger State and the country at large, through a regular assessment of the impact of such exercise on the beneficiaries.
Table of Contents—————————————————————————————–vi
List of Tables———————————————————————————————-ix
List of Abbreviations————————————————————————————-x
CHAPTER ONE 1.0 INTRODUCTION———————————————————————————-1
1.1 Background to the Study—————————————————————————-1
1.2 Statement of the Problem—————————————————————————5
1.3 Objectives of the Study—————————————————————————–7
1.4 Research Questions———————————————————————————7
1.5 Significance of the Study ————————————————————————–8
1.6 Scope of the Study———————————————————————————-9
1.7 Limitations of the Study—————————————————————————-9
1.8 Definitions of Key Terms————————————————————————-10
CHAPTER TWO 2.0 LITERATURE REVIEW/THEORETICAL FRAMEWORK————————–11
2.1 Introduction —————————————————————————————-11
2.2 The Extension of the Communication field—————————————————-11
2.3 The Conceptualization of Group Communication———————————————13
2.3.1 Characteristics of Groups———————————————————————-15
2.3.2 Types of Groups and its Formation———————————————————–16
2.3.3 Why groups are formed————————————————————————18
2.3.4 Group stages————————————————————————————-19
2.4 Applying Behavioral Change Communication (BCC) to address child delivery at Home———————————–21
2.5 Some Health Communication Campaigns used to create awareness about an existing Health Issue———————-23
2.6 National Hospital Discharge Survey (NHDS) ———————————————-27
2.7 Review of Studies on Child Delivery at Home———————————————-28
2.8 Effective Communication———————————————————————-35
2.8.1 Group Communication and its effectiveness to discourage child delivery at home in Niger State—————————37
2.9 Theoretical Framework————————————————————————-40
2.9.1 Health Belief Model and its Assumptions—————————————————40
2.9.2 Criticisms of Health Belief Model————————————————————42
CHAPTER THREE 3.0 RESEARCH METHODOLOGY————————————————————-44
3.2 Research Design———————————————————————————–44
3.4 Sampling Technique——————————————————————————46
3.5 Sampling Size————————————————————————————-47
3.6 Method of Data Collection———————————————————————-48
3.7 Instruments for Data Collection—————————————————————-48
3.8 Validity and Reliability of the Instrument—————————————————-49
3.9 Method of Data Analysis ———————————————————————–50
CHAPTER FOUR 4.0 PRESENTATION, INTERPRETATION AND ANALYSIS OF DATA———–51
4.2 Data Presentation and Analysis—————————————————————-51
4.3 Discussion of Findings————————————————————————–62
4.4 The Group Communication Campaign in Niger State within the period of 2012-2014 ————————63
5.0 SUMMARY, CONCLUSION AND RECOMMENDATION————————–70
5.4 Suggestions for further Study——————————————————————-74
5.5 Contribution of Study—————————————————————————-74
LIST OF TABLES
Table 4.1 Distribution of respondents by Local Government Area 52
Table 4.2 Distribution of respondents by age 53
Table 4.3 Distribution of respondents by marital status 53
Table 4.4 Distribution of respondents by occupation 54
Table 4.5 Distribution of respondents by qualification 54
Table 4.6 Distribution of respondents by their awareness of the campaign 55
Table 4.7 Distribution of respondents by their knowledge of the campaign 55
Table 4.8 Distribution of respondents by their attendance of the campaign 56
Table 4.9 Distribution of respondents by their reason for not attending the campaign 56
Table 4.10 Distribution of respondents by their frequency of the attendance 57
Table 4.11 Distribution of respondents by their perception of the campaign 57
Table 4.12 Distribution of respondents by their child delivery in the hospital 58
Table 4.13 Distribution of respondents by their reasons for child delivery at home 58
Table 4.14 Distribution of respondents by the influence of the campaign 59
Table 4.15 Distribution of respondents by their continuity to patronise the hospital 59
Table 4.16 Distribution of respondents by their rating of the campaign 59
LIST OF ACRONYMS MSS Midwife Service Scheme
PHC Primary Health Care NPHCDA: National Primary Health Care Development Agency
MDGs Millennium Development Goals
TBA Traditional Birth Attendants
SBA Skilled Birth Attendance
WHO World Health Organisation
HIV/AIDS Human Immune Virus/ Acquired Immune Deficiency Sydrome
NGOs Non Governmental Organisations
UNICEF United Nations International Children’s Emergency Fund
UNFPA United Nation Population Fund
MMR Maternal Mortality Ratio
INTRODUCTION 1.1 BACKGROUND TO THE STUDY The desire to procreate is an obligation common to all human societies, particularly the female species except for some reasons that could prevent some from partaking in this responsi-bility. In an attempt to fulfill this desire, many women lose their lives during childbirth especial-ly in developing countries. Pregnancy-related complications are among the leading causes of death and disability among women in Nigeria and for every woman who dies, other women suf-fer injury, infection or disease (Dahiru, n.d). Maternal mortality rate, according to United Na-tions International Children’s Emergency Fund -UNICEF (2014), is higher in areas where wom-en have many babies in short time spans under malnutrition, bad hygienically conditions and lack of access to medical treatment.
Abimbola, Okoli, Olubajo, Abdullahi and Pate (2012) posit that maternal, new born and child health indices in Nigeria vary widely across geopolitical zones. There are urban and rural variations with maternal mortality ratio (MMR) of 351/100,000 live births in urban areas com-pared to 828/100,000 in rural areas. This may be as a result of the variations in the availability of skilled attendance during child delivery. To improve these indices, the Midwives Service Scheme (MSS) funded under the MDGs-DRG, 2009 Appropriation Act; 2,488, deployed unem-ployed and retired midwives to 652 primary health care facilities in 332 Local Governments carefully selected in all the 36 states and FCT (MDG-DRG Funded Midwives Service Scheme, 2009). With a collaborative effort between the Federal Ministry of Health and core partners in the Maternal and Child Health efforts, the Midwife Service Scheme is an intervention designed to address shortage of skilled birth attendants at primary health care level in Nigeria.
According to the National Primary Health Care Development Agency (2013), several in-itiatives and programme have been introduced over the years to reduce mortality among women in Nigeria. Despite these efforts implemented by National Primary Health Care Development Agency (NPHCDA), poor maternal and child health indices has continued to be one of the most serious development challenges facing the country. NPHCDA established the Midwives Service Scheme (MSS), a public sector collaborative initiative, designed to mobilise midwives, including newly qualified, unemployed and retired midwives, for deployment to selected primary health care facilities in rural communities. It is aimed at facilitating an increase in the coverage of Skilled Birth Attendance (SBA), to reduce maternal, newborn and child mortality. Nigeria has had a very poor record regarding maternal and child health outcomes. An estimated 53,000 women and 250,000 newborn die annually mostly as a result of preventable causes. The NPHCDA, under the 2009 Appropriation Act, was tasked with establishing the MSS. The MSS is a public sector initiative and a collaborative effort between the three tiers of government in Nigeria. A memorandum of understanding (MOU) between the Federal, State and Local gov-ernments was signed by all 36 states of Nigeria and was set out clearly to define shared roles and responsibilities, which are supported by the strategic partners of the midwives (National Primary Health Care Development Agency, 2013). This intervention is aimed at bringing the midwives closer to the women to assist them with the necessary obstetric care needed before, during and after child delivery.
Receiving updates, reviewing progress and offering advice in order to provide strategic direction, support and guidance for the implementation of the MSS is done by a Technical Work-ing Group (TWG). The secretariat of the MSS is responsible for day-to-day management, whilst state focal persons serve as a contact for the midwives in the MSS. The MSS is based on a clus-
ter model in which four selected primary healthcare facilities with the facility to provide Basic Essential Obstetric Care (BEOC) are clustered around a General hospital with capacity to pro-vide Comprehensive Emergency Obstetric Care (CEOC). A midwife is deployed to each selected PHC, ensuring 24 hour provision of medical care services and access to skilled attendance at all births to reduce maternal, newborn and child mortality and morbidity. The MSS currently covers 163 clusters, which have 652 PHCs and 163 general hospitals. The MSS has estab-lished/reactivated ward development committees at all MSS PHCs to ensure community partici-pation and ownership in its implementation (National Primary Health Care Development Agen-cy, 2013). The midwives posted to various rural communities help to educate both the unin-formed and the misinformed women about the need for them to be mindful of their health during pregnancy stage and child delivery stage and the need to avoid child delivery at home. MSS create a framework aimed at improving the skills and proficiency of midwives in provision of quality maternal and child health services.
The outcome of the MSS, according to Daniel, Usman and Stephen (2012) has been an uneven improvement in maternal, newborn, and child health indices in the six geopolitical zones of Nigeria which may be as a result of communication. Hence, there is the need for women, par-ticularly in rural communities, to be aware of the prevailing issue of maternal mortality. Com-munities, particularly women, need to be educated about complications that may arise before, during and after childbirth at home. To bridge this gap, various face-to-face communication campaigns are being carried out in various communities. Communication, particularly verbal, occurs when one person speaks and another listens. Health workers uses range of verbal commu-nication skills to respond to questions, find out about an individual‘s problems or needs, contri-bute to team meetings, break bad news, provide support to others and deal with problems and
complaints. According to MDG-DRG Funded Midwives Service Scheme (2009) there is short-age of skill attendants which may impact negatively on the utilisation of services by women. De-spite the intervention of international organisation, gaps still exist. These gaps range from infra-structure, communication gap, access to services and human resource needs in many health facil-ities across Nigeria. The enormity of the problems in the health sector and the realisation that nothing much could be achieved without convincing the people involved on some aspects of health have forced the stakeholders in the health sector to give premium to communication (Adeyanju, 2008). One of the major communication campaigns carried out Niger State is the group communication campaign where women are gathered in a group (within the primary health centers) to address the issue of child delivery at home through the orientation offered by the midwives. According to Smith (2011:2), ―group communication refers to the communication that exists between two or more people‖. This type of communication is used in health and social care where issues and complaints are addressed in groups, particularly to improve maternal health by avoiding compli-cations (like stillbirth after the start of labour, the child dying within the first week of birth, brain injury, fractures to the upper arm or shoulder during birth, and faeces in the lungs) arising from childbirth at home.
Igberase, Isah and Igbekoyi (2009) affirms that efforts should be directed towards educat-ing women about the risk of delivering at homes of traditional birth attendants adding that pro-viding information to women on prevention of maternal mortality and community participation and mobilisation will help prevent maternal mortality to some extent in Nigeria. Igberase, Isah and Igbekoyi (2009) added that informing and educating women will help create awareness that could reduce maternal mortality to the barest minimum. In group communication, patients are
likely to open up to a social worker about issues if they are around people of similar situations. Different languages, cultures and psychological factors exist which makes it difficult for every social worker to fully comprehend verbally what their patients are complaining about in a typical group communication; so in cases like this, effective communication and interaction (with the patients) can play an important role in the work of all health and social care professionals. To help improve maternal health of women in Niger State in particular, the MSS carry out a group communication campaign where pregnant women and nursing mothers are gathered in a group, particularly in primary health centres, educating and enlightening them on the need to avoid child delivery at home by visiting health centres for proper check up. 1.2 STATEMENT OF THE PROBLEM According to Boucher, Bennett, McFarlin and Freeze (2009), the top five reasons why women prefer home delivery are: safety, avoidance of unnecessary medical interventions com-mon in hospital births, previous negative hospital experiences, more control and comfortable and familiar environment. For Titaley, Hunter, Dibley & Heywood (2010) physical distance and fi-nancial limitations were two major constraints that prevent most community members from ac-cessing and using trained attendants and institutional deliveries. While Montagu et al (2011) rea-sons for women‘s preference to home delivery are; costs, access and facility.
As part of the efforts to help reduce maternal deaths in Nigeria, pregnant women are en-couraged to give birth in healthcare centers under the supervision of a skilled birth attendant. To promote this, the NPHCDA made available nurses and midwives in primary healthcare centers in order to offer obstetric care to women, yet, some women particularly in rural communities still deliver their child at home leading to preventable complications. In most cases, when this occurs,
some women may experience normal delivery while some may also be at risk of pregnancy-related complications and resultant morbidity and mortality. It is for this reason that midwives were deployed to primary healthcare centers in various rural communities for the sole purpose of curbing this societal menace. A research conducted by Babalola and Fatusi (2009), shows that majority of women who deliver their child outside health centres delivered either in a separate room or inside the house and attended to by neighbours, traditional birth attendants or family members. Despite the availability of skilled birth attendants at MSS facilities, according to Abimbo-la, Okoli, Olubajo, Abdullahi and Pate, (2012), women still deliver at home in some parts of the country which poses a major challenge to this scheme, particularly in achieving the objectives of MDG5—improving maternal mortality—by the year 2015. Therefore, in an effort to reduce mor-tality amongst women of Niger State, using the group communication campaign, women were educated and informed by midwives (in collaboration with the state government) on the dangers associated with child delivery at home. In carrying out this awareness campaign, women were gathered and educated in various primary health centers in diverse communities of Niger State. Yet, some women continue to die while some continue to encounter complications during child-birth at home. The question that came to mind as a result of the continued deaths and complica-tions arising from child delivery at home bothers on whether the communication campaign car-ried out by MSS was not having a desired impact on the phenomenon. It is on this basis that this study was carried out to assess the effectiveness or ineffectiveness of the group communication campaign currently in use by MSS as a way of determining its adequacy in addressing the prob-lem of child delivery at home in Niger State.
1.3 OBJECTIVES OF THE STUDY
This study was aimed at assessing the group communication campaign applied by MSS in creating awareness of maternal health issues among the rural women of Niger state. For this reason, this study was guided by the following objectives:
1. To find out the causes of child delivery at home among women of Niger State.
2. To assess how the campaign is able to address the problem of child delivery at home among women in Niger state.
3. To find out the challenges that are limiting the effectiveness of the campaign carried out by midwives in the fight against child delivery at home.
4. To determine how these challenges can be addressed, if any.
1.4 RESEARCH QUESTIONS This study was guided by the following research questions;
1. What are the causes of child delivery at home among women of Niger State?
2. How is this campaign able to address the problem of child delivery at home among wom-en of Niger State?
3. What are the challenges that are limiting the effectiveness of the campaign carried out by MSS in addressing the problem of child delivery at home in Niger State?
4. What should be done to address these challenges, if any?
1.5 SIGNIFICANCE OF THE STUDY
Without attention to the type, quality, and distribution of facilities, Nigeria will be unable to reduce maternal mortality to the degree it aspires (Daniel, Usman & Stephen, 2012). One of the factors that prevent women from seeking or receiving care during pregnancy and childbirth is lack of information (WHO, 2012) which the Niger State women are not lacking. This is because women in Niger State are informed and educated collectively (in a group) by midwives in PHCs
on the need to visit health centres for proper antenatal and postnatal care and to avoid childbirth at home. It is a common terrain for women, particularly in rural communities, to deliver at home. Some are successful while the unsuccessful ones encounter complications that ordinarily would have been avoided if they had visited health centres. Thus, a study of this context was seen as a significant ways of suggesting means by which this group communication campaign can be ef-fectively carried out by the MSS to discourage child delivery at home. This study is relevant to the MSS programme initiators and coordinators, the Niger State government and international organisations in order to understand the importance of group and face-to-face communication aimed at reaching out to women (particularly in rural communities) and to recognise the extent the MSS campaign will go in curbing maternal mortality in Nigeria, particularly in Niger State. Several studies on health communication campaign on malaria, fami-ly planning, polio vaccines, HIV/AIDS and others have been carried out by different researchers; but there are limited studies conducted in the area of the use of group communication approach and other forms of communication approach in addressing maternal mortality in Nigeria. There-fore, this study adds to the existing body of knowledge through its assessment of the group communication campaign currently in use by the MSS about health care visit by women in Niger State which will also serve as an empirical reference material for further study. 1.6 SCOPE OF THE STUDY
Various traditional societies, according to Aiyedun (1995), live in Niger State like the Nupes, Gwaris, Kambaris and the Hausas. Out of the estimated total population of 3,950,249 in 2006, eighty five percent are farmers while fifteen percent are involved in vocations such as white collar jobs, business, craft and arts (Niger State Geographic Information System, 2008).
This study covered women (pregnant women and nursing mothers) in Niger State. Three local government areas (Paikoro, Chanchanga and Lapai) were selected through balloting from the 33 local government areas in Niger State. 1.7 LIMITATIONS OF THE STUDY Some of the limitations this study encountered were: Language barrier/literacy level: due to the inability to speak the dominant language within the community, the researcher had to employ a woman who was domicile within the State as well as speak and understand English language and their dominant language so as to be able to interpret and communicate the researcher‘s message to the respondents within the study area. This woman went all places with the researcher which was very strenuous because there were occasions when the woman wanted restricting herself from moving further. Other limitations encountered were: inability to extract adequate information from some mid-wives and nurses, inability to gain full access to the hospital‘s maternal record book, distance, bad roads and finance. 1.8 DEFINITIONS OF KEY TERMS MSS Midwife Service Scheme PHC Primary Health Care NPHCDA: National Primary Health Care Development Agency MDGs Millennium Development Goals TBA Traditional Birth Attendants
SBA Skilled Birth Attendance
MMR Maternal Mortality Ratio
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