factors affecting utilisation of maternal health …
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FACTORS AFFECTING UTILISATION OF MATERNAL
HEALTH CARE SERVICES AMONG PREGNANT MOTHERS:
A CASE OF BUMBULI DISTRICT COUNCIL
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FACTORS AFFECTING UTILISATION OF MATERNAL
HEALTH CARE SERVICES AMONG PREGNANT MOTHERS:
A CASE OF BUMBULI DISTRICT COUNCIL
By
Prisca M. Kiango
A Dissertation Submitted in Partial Fulfilment of the Requirements for Award
of Master Degree of Health Systems Management of Mzumbe University
2015
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CERTIFICATION
The undersigned certify that he has read and hereby recommends for acceptance by
the Mzumbe University, titled: “Factors affecting utilisation of maternal health
Care services among pregnant mothers: A case of Bumbuli District council” in
partial fulfilment of the requirements for the degree of Master of Health System
Management (MHSM) of Mzumbe University.
___________________________
Major Supervisor
___________________________
Internal Examiner
___________________________
External Examiner
Accepted for the Board of School of Public Administration and Management
Signature ……………………………..
DEAN/CHAIRPERSON
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DECLARATION
I, Prisca .M. Kiango, declare that this dissertation is my own original work and it has
not been presented and will not be presented to any other university for a similar or
any other degree award.
Signature………………………............
Date……………………………………
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COPYRIGHT
This dissertation is a copyright material protected under the Berne Convention, the
Copyright Act 1999 and other international and national enactments, in that behalf,
on intellectual property. It may not be reproduced by any means in full or in part,
except for short extracts in fair dealings, for research or private study, critical
scholarly review or discourse with an acknowledgement, without the written
permission of Mzumbe University, on behalf of the author.
©
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ACKNOWLEDGEMENTS
First and foremost, I would like to thank Almighty God for giving me this
opportunity and enabling me in every step of my studies at Mzumbe University,
without His graciousness and help my endeavour would be unsuccessful.
I also offer my heartfelt gratitude to my supervisor Mackfallen Anasel. for his
meticulous academic advice. Indeed his valuable comments, challenges and
encouragements were fundamental in shaping and producing this dissertation. I
commend and thank him for the tireless expert opinions and a unique guidance
during this research from the proposal stage to report completion. I am deeply
indebted to him.
I gratefully appreciate the contribution of knowledge by the rest of my course
lecturers, for their support. I would also like to extend my deepest appreciation to my
fellow students for their cooperation throughout my studies at Mzumbe.
A special word of thanks go to Dr Martin Kiango his support, presence,
encouragements and prayers, He was very tolerant and understanding on my absence
at home during my studies at Mzumbe and when I was writing this dissertation. I
warmly acknowledge him.
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DEDICATION
This work is dedicated to my beloved parents, father Martin M. Kiango and mother
Edna Sesala, my twin Michael Kiango, my sisters Jane, Mary and Happy, my brother
Vincent whose understanding on the importance of education influenced my interest
in schooling, This work is a product of their early efforts.
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LIST OF ABBREVIATIONS AND ACRONYMS
ANC Antenatal Care Services
BBA Born Before Arrival
CBR Crude Birth Rate
MDG5
MHCs
Millennium Development Goals number five (5)
Maternal Health Care Service
MMR Maternal Mortality rate
NED-ELCT North Eastern Diocese of the Evangelical Lutheran Church of
Tanzania
PHC
FGD
Primary Health Care
Focus Group Discussion
TBA Traditional Birth Arrive
TDHS Tanzania Demographic Health Survey
UNICEF United Nations Children's Fund
WHO World Health Organisation
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ABSTRACT
This study assessed the factors affecting utilisation of maternal health care services
among pregnant mother intends to establish reasons why mothers decide to deliver in
the different sites. The objectives of this study were: determining social –
demographic factors affecting utilization of maternal health care services among
pregnant mothers, ascertaining ways through which health systems affect utilisation
of maternal health care services among pregnant mothers and determining the
cultural beliefs and practices that have an effect on utilisation of maternal health care
services among pregnant mothers.
The study employed community cross-sectional design. It employed a total of 110
respondents of this study. Data for this study were collected through questionnaires,
interview and focus group discussion. The quantitative data were analysed by using
Statistical Package for Social Sciences (SPSS) where as the qualitative data were
analysed content analysis.
The findings of the study revealed that maternal health services utilisation is highly
affected by socio-demographic factors such as occupation, age, marital status and
level of education. The distance from residential home to the facility also affect the
utilisation of MHCS. The healthy system such as poor customer service of the
facility human resource, ability of the women to pay for the MHCS also bar them to
utilise the service. It was also realised that, the cultural beliefs and practices such fear
for operation, trust on the TBA, power of confidence, etc. Affect the utilisation of
MHCS.
It is recommended that, the unmarried, uneducated, peasant and aged 15-20 years old
women should be sensitized on full utilising the service for the benefits and future
generation reproduced by such women.
Further study is recommended in more than 3 wards and in other districts in
Tanzania with large sample. The further study is also suggested to be done in urban
areas as this one was done in the rural areas.
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TABLE OF CONTENTS
CERTIFICATION ........................................................................................................ i
DECLARATION ......................................................................................................... ii
COPYRIGHT .............................................................................................................. iii
ACKNOWLEDGEMENTS ........................................................................................ iv
DEDICATION ............................................................................................................. v
LIST OF ABBREVIATIONS AND ACRONYMS .................................................... vi
ABSTRACT ............................................................................................................... vii
TABLE OF CONTENTS .......................................................................................... viii
LIST OF TABLES ...................................................................................................... xi
LIST OF FIGURES ................................................................................................... xii
CHAPTER ONE ........................................................................................................ 1
INTRODUCTION OF THE STUDY ....................................................................... 1
1.1 Introduction ............................................................................................................ 1
1.2 Background to the study......................................................................................... 1
1.3 Statement of the Problem ....................................................................................... 5
1.4 Objectives of the Study .......................................................................................... 7
1.4.1 General Objective................................................................................................ 7
1.4.2 Specific Objectives.............................................................................................. 7
1.5 Research Questions ................................................................................................ 7
1.6 Significance of the Study ....................................................................................... 8
1.7 Scope of the Study ................................................................................................. 8
1.8 Organisation of Dissertation .................................................................................. 8
CHAPTER TWO ....................................................................................................... 9
LITERATURE REVIEW .......................................................................................... 9
2.1 Introduction ............................................................................................................ 9
2.2 Definition of Key Concepts ................................................................................... 9
2.2.1 Maternal Health Care .......................................................................................... 9
2.2.2 Maternal Mortality .............................................................................................. 9
2.2.3 Maternal Morbidity ............................................................................................. 9
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2.2.4 Antenatal Care ................................................................................................... 10
2.2.5 Postnatal Care.................................................................................................... 10
2.2.6 Traditional Birth Attendant (TBA) ................................................................... 10
2.2.7 Born Before Arrival (BBA) .............................................................................. 10
2.3 Theoretical Literature Review.............................................................................. 10
2.3.1 Health Care Utilisation Theories and Models ................................................... 10
2.3.2 Andersen Healthcare Utilisation Model ............................................................ 11
2.3.3 Health Belief Model (HBM) ............................................................................. 12
2.4 Empirical Literature Review ................................................................................ 12
2.5 Factors Influencing the Use or Non Use of Health Services ............................... 13
2.6 Barriers of Utilising Maternal Health Care Services ........................................... 13
2.7 Improving Utilisation of Maternal Health Care Services .................................... 18
2.8 Summary of Literatures and Study Conceptualising. .......................................... 18
2.9 Conceptual Framework ........................................................................................ 19
CHAPTER THREE ................................................................................................. 22
RESEARCH METHODOLOGY ........................................................................... 22
3.1 Introduction .......................................................................................................... 22
3.2 Type of the Study and Research Design .............................................................. 22
3.3 Study Area ............................................................................................................ 22
3.4 Study Population .................................................................................................. 23
3.5 Units of Analysis .................................................................................................. 23
3.6 Variables and their Measurements ....................................................................... 24
3.7 Sample Size and Sampling Techniques ............................................................... 24
3.8 Types and Sources of Data ................................................................................... 26
3.9 Data Collection Methods ..................................................................................... 26
3.9.1 Structured Questionnaire ................................................................................... 27
3.9.2 Interview Guide Questions ................................................................................ 27
3.10 Validity and Reliability ...................................................................................... 27
3.11 Data Analysis Methods ...................................................................................... 28
3.12 Ethical Consideration ......................................................................................... 29
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CHAPTER FOUR .................................................................................................... 30
PRESENTATION OF FINDINGS AND DISCUSSION ...................................... 30
4.1 Introduction .......................................................................................................... 30
4.2 Respondents Social Demographic Factors ........................................................... 30
4.3 Social-Demographic Factors Affecting Utilisation of Maternal Health Care. ..... 32
4.4 Delay in Assisting Maternal Patients ................................................................... 40
4.5 Reasons for Choice of Place of Delivery ............................................................. 41
4.6 Health Systems and Utilization of Maternal Health Care Services Among
Pregnant Mothers in Bumbuli District Council. ........................................................ 41
4.7 Cultural Beliefs and Practices and Utilization of MHCS..................................... 42
CHAPTER FIVE ...................................................................................................... 43
SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS . 43
5.1 Introduction .......................................................................................................... 43
5.2 Summary of Findings ........................................................................................... 43
5.3 Conclusion ........................................................................................................... 43
5.4 Recommendations ................................................................................................ 44
5.4.1 Regarding Health System on utilisation of Maternal Health Care Services. .... 44
5.4.2 Regarding Socio–Demographic Factors on Utilisation of Maternal Health Care
Services ...................................................................................................................... 45
5.4.3 Regarding Cultural Beliefs and Practices on Utilisation of Maternal Health
Care Services .............................................................................................................. 46
5.5 Limitations and scope for further study ............................................................... 47
REFERENCES ......................................................................................................... 48
APPENDICES .......................................................................................................... 53
Appendix 1 QUESTIONNAIRES (English version) ................................................. 53
Appendix 1: Dodoso kwa akina mama ...................................................................... 56
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LIST OF TABLES
Table 1.1 Reproductive and child health attendance. .................................................. 5
Table 4.1. Respondent’s Socio-Demographic Factors ............................................... 32
Table 4.2: Association Between Social-demographic Factors and Mothers
Attendance to Antenatal Clinic. ................................................................. 34
Table 4.3: Socio-demographic characteristics and choice of a place of delivery ...... 36
Table 4.4 Frequency of antenatal clinic visits in the last pregnancy among
respondents ................................................................................................ 37
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LIST OF FIGURES
Figure 2.1: Andersen Healthcare Utilisation Model .................................................. 12
Figure 2.2: The Relationship Between the Variables Under Consideration .............. 20
Figure 4.1. Percentage distribution of women by Place of delivery .......................... 35
Figure 4.1: Whether or not respondents pay for ante-natal services .......................... 37
Figure 4.2 Type of Cost Incurred Seeking Maternal Care Among Study Participants
.................................................................................................................................... 38
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CHAPTER ONE
INTRODUCTION OF THE STUDY
1.1 Introduction
This chapter presents a study background which comprises overview, trend and
status of the maternal health care services, statement of the problem, objectives of the
study, significance of the study, scope and organisation of the study.
1.2 Background to the study
An improvement of the maternal health care service among pregnant mothers in
developed and developing countries is considered as one of the key important issue
for socio – economic development. This is due to the fact that for sustainable socio –
economic development, human capital as one of integral part has to be developed.
One way of developing human capital is through provision of good health care
services. At the Millennium Summit in September 2000 the largest gathering of
world leaders in history adopted the United Nation Millennium Declaration,
committing their nations to a new global partnership to reduce extreme poverty and
setting out Millennium Development Goals (MDG’s). One of the Millennium
Development Goal’s was to improve maternal health which aimed to improve
maternal health care services among pregnant mothers and reduce maternal
mortality.
Despite of global and national efforts to improve women’s health, death of women
during childbirth remains an unresolved challenge in many developing countries
including Tanzania. Some estimates indicate that at least half million women die
from pregnancy related causes (World Bank, 2007). The estimates further show that
99 percent of these deaths occur in developing countries especially in sub – Saharan
Africa and there is slow pace in reducing maternal mortality compared to other
regions of the world from 1990 to 2005. While the overall global decline in maternal
mortality ratio between 1990 and 2005 was 5.4 percent, the annual decline was less
than 1 percent (World Bank, 2007).
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According to World Bank (2007), the situation was noted to be worse in sub –
Saharan Africa where the decline was 0.1percent. Most of the maternal deaths were
caused by factors attributed to pregnancy, childbirth and poor quality of health
services. About 60% of the maternal death occurs during labour, delivery and
immediately after delivery. This report shows that, irrespective of the different
strategies made by the governments of the developing countries still there is a big
challenge of addressing the problem of addressing maternal mortality and improving
the provision of good maternal health care service among pregnancy mothers.
In Tanzania various reforms have been made in health sector since independence up
to date with the ultimate aims of improving maternal health care services. These
reforms includes formulating various health policies and strategies of increasing
quantity and accessibility to health services as well as improving quality of health
services and increasing. Soon after gaining independence in 1961 the government
directed his efforts to put special emphasis on improving health and social care
services. This was due to the reality that a large segment of Tanzania's population,
particularly those in rural areas were poor and had only limited access to basic health
services or no access at all (Kapoka, 2000).
The 1967 Arusha Declaration sought to restructure the health sector as part of a
comprehensive strategy to ensure sustainable development based on the principles of
socialism and self-reliance. Steps were taken to abolish existing rural-urban bias to
establish a viable rural health care network within the spirit of self-reliance. But
perhaps the most significant outcome of the Arusha Declaration in the field of health
were efforts to make health care services comprehensive, universally accessible, and
free of out of pocket payments to the general public (Kapoka, 2000). Rural health
services and preventative medicine were allocated Tsh.31m in the Second Plan of
which Tsh.27m was allocated to rural health centres (van Etten, 1976). This amount
by that time is considerably large compared to 8.9 % which was allocated to the
health in the fiscal year 2011/12 (Baltussen & Niessen, 2006).The delivery of health
services was to be through health centres, dispensaries and village health centres.
Health care service provision was aimed at reaching rural and urban communities to
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include the poor who could not afford the cost of health care and those who could
afford to pay for their health care.
Health services were provided free of charge by government institutions while
voluntary agencies charged modest fees. Given the reality that over 80 percent of the
population lived in rural areas, development of the rural health infrastructure was
given high priority. Hospitals were built in each region and there was also a shifting
of emphasis from curative to preventive care (Mukong,2012). These measures
allowed the majority of Tanzanians especially pregnant mothers to have access to
health services and improve the quality of life.
This was due to the fact that most of the Tanzanian especially poor families that were
initially not able to pay for maternal health care services had access to health services
due to elimination of charger fees on health services. Having made extensive
progress towards provision of health for all in Tanzania in the 1970s and early 1980s,
Tanzania faced severe challenges to continue providing health services to the bulk of
its population. This was due to an increase in demand for health services which were
provided free of charge with respect to ability of the government to finance the
provision of such services. During this period, the Government was the key provider
of free health care services whereas private health care provisions were nearly
nonexistent except for a few faith-based health care facilities (MOH, 1994)
The government continued to take initiatives toward improving maternal health care
services by making reforms formulating policies, guidelines, plans and strategies in
health sector. Deregulation and liberalisation of the health care sector since the early
1990s was part of the overall socioeconomic reforms that took place in the country.
Training and employing maternal health expertise and decentralisation to Region and
district was part of the reforms. Ministry of Health continued to give overall policy
guidelines, implementation of health programmers was done by regional and local
governments, voluntary agencies and private sectors (MoH,1990).
Reforms in health care sector resulted into introduction of cost sharing in health
services. Similarly, there was an increase in involvement of private health providers
whose services were fee –based (Tibandebage et al, 2001).
4
The liberalisation of the health care sector was also associated with the introduction
of user fees in the public health care provision. The intention of introducing user fees
was to generate additional revenue to facilitate improvement in availability and
provision of quality health care services (MoH, 1994). In order to promote equity in
accessing health services, following the introduction of the user fee, equity-seeking
mechanisms such as having maternity wards and gynaecological doctors. The
mechanisms were introduced to protect the poor and other vulnerable groups
including pregnant mothers who are unable to pay the fees.
Following these reforms, the 2004/05 Demographic and Health Surveys (DHS) show
that pregnant related mortality was not significantly reduced over the last two
decades. The maternal mortality ratio for the period 1995 to 2004 was 578 per
100,000 live births, not significantly different from the 1987 to 1996 ratio of 529 per
100,000 live births. However, the 2009/2010 DHS show substantial reduction from
578 to 474 maternal deaths per 100,000 live births. Nationally, between 1999 and
2004, there was a slight increase in the proportion of births assisted by health
professionals, from 41 % in 1999 to 46 % in 2004 (Mujinja and Kida, 2014). From
1978 to 2012, infant mortality fell from 137 to 68 per 1,000 live births, and under-
five mortality declined from 231 to 162 in 2002 and to 68 per 1,000 live births in
2012 (URT, 2013). The demographic and health surveys shows that infant mortality
rate has decreased from 58 per 1,000 live births in 2007/2008 (URT, 2008) to 51 per
1,000 live births in 2010 (DHS, 2010).
In Bumbuli District Council various plans and strategies have been made to improve
maternal health care services following decentralisation of health sector to regions
and districts made during the 1990s reforms. The strategies that have been taken by
Bumbuli District Council to improve utilisation of health care services among the
pregnant mothers includes Harmonisation of women to attend antenatal and postnatal
health care service, to employ more personnel staff and supply enough medicines and
medical equipment in all health centres and dispensaries. Other strategies includes on
job training on how to provide maternal health care services among the pregnant
mothers including hospitality during the provision and providing motivations among
workers.
5
According to Bumbuli District council’s annual health reports the attendance of
maternal women in health centres and dispensaries is not satisfactory irrespective of
the measures taken by the council. Although the attendance has been increasing
yearly from 2010 to 2014. The antenatal attendance was 2562 in 2010 while in 2014
was 4170 showing an increase of almost 63 percent. The delivery health centres was
447 in 2010 and 1885 in 2014. The Born Before Arrival (BBA) to health care centres
were 47 in 2010 and 62 in 2014 indicating an increase of 15 births. Furthermore, the
Bumbuli District Council’s report shows that home delivery decreased from 120 in
2010 to 101 in 2014, while the Traditional Birth Attendance (TBA) decreased from
408 in 2010 to 395 in 2014 (Bumbuli District Council Annual Health Report,2015).
The annual attendance of antenatal, delivery health centre, BBA, TBA, home
delivery and postnatal attendance from 2010 to 2014 have been presented in table
1.1.
Table 1.1: Reproductive and child health attendance
Year 2010 2011 2012 2013 2014
Antenatal 2562 2230 3693 3140 4170
Delivery health centres 447 348 722 805 1885
BBA 47 52 46 53 62
TBA 408 392 406 362 395
Home delivery 120 110 65 98 101
Postnatal 3 to 7 hours 225 322 401 506 629
48 hours 86 231 328 682 784
Source: Bumbuli District Council annual health reports 2015
The existence of large number of maternal health mothers attending TBA and BBA
offers a chance to investigate the factors affecting utilisation of maternal health care
services among pregnant mothers and suggest the measures improve the situation.
1.3 Statement of the Problem
Maternal death rate is regarded as one of the bottleneck of social – economic
development in most of the developing countries. In most cases these deaths occurs
before, during and after delivery. The 2004/05 Demographic and Health Surveys
(DHS) shows that pregnant related mortality was not significantly reduced over the
last two decades in Tanzania. As one of the Millennium Development Goals, most of
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the countries through their respective governments have being trying to reduce it by
taking measures to improve quality and accessibility to maternal health care services.
Tanzania is one among the countries that have been formulating various strategies
for improving maternal healthcare services. However, for the government and other
stakeholders to take suitable actions to improve maternal health care services
successfully, accurate information towards the problem that relies on empirical
investigation is needed. Few studies have been undertaken to investigate the factors
responsible for under utilisation of maternal health care in Tanzania. Gwamaka
(2000) revealed that socio – economic factors, social cultural factors, social
demographic characteristic, and health service factors were affecting delivery in
health facility among delivery women in Nkasi district. Shija (2001), found that,
inadequate infrastructure, poor communication and transport between health facilities
and district hospital, inadequate number of skilled personnel and irregular supplies of
essential medicines and equipment make the accessibility of this important
intervention not possible to a greater number of women in Tanzania.
Mukong (2012) stated that socioeconomic factors such as household income,
maternal education, paternal education, Health knowledge as well as distance to
facility are positively associated with maternal health care utilisation in Tanzania.
Having few studies conducted to investigate the phenomenon and with no study
which have been undertaken in Bumbuli District Council it gives an insight of
conducting research. Furthermore, despite the improvement of some targeted
indicators there do still exist challenges on accessibility, quality, quantity and equity
in health care delivery. This situation therefore calls for research to inform the
relationship between the accessibility variables, socio-economic determinants,
income and wealth distribution and health indicators to confirm the nature of the
relationship between maternal health care services and utilisation of the same.
Therefore this was set out to assess the factors affecting utilisation of health care
services among pregnant mothers.
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1.4 Objectives of the Study
1.4.1 General Objective
The overall objective of the study was to examine the factors affecting utilisation of
maternal health care services among pregnant mothers in Bumbuli District council.
1.4.2 Specific Objectives
An assessment of the general objective of the study was done by specifically
investigating the following objectives
i. To determine social – demographic factors affecting utilisation of maternal
health care services among pregnant mothers
ii. To ascertain ways through which health systems affect utilisation of maternal
health care services among pregnant mothers
iii. To determine the cultural beliefs and practices that have an effect on
utilisation of maternal health care services among pregnant mothers
1.5 Research Questions
An assessment of the factors affecting utilisation of maternal health care
services among pregnant mothers was guided by the following specific research
questions;
i. What are the social – demographic factors that affect utilisation of maternal
health care services among pregnant mothers?
ii. What are the cultural beliefs and practices that affect utilisation of maternal
health care services among pregnant mothers?
iii. How do health systems affect utilisation of maternal health care services
among pregnant mothers?
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1.6 Significance of the Study
Understanding factors that hinders delivery in health facilities are particularly
important in order to narrow the existing gaps among Council and improve quality of
health service delivered to pregnant mothers to reduce maternal morbidity, mortality
and disabilities that are related to pregnant and childbirth. Accurate information that
prevents women to deliver in health facilities while large number of them attend
antenatal clinic at least once in their period of pregnant and less than half deliver in
health facilities are required.
The aim of the study was to assess the factors affecting utilisation of maternal health
care service among pregnant mothers. The findings of the study will be helpful to
health sector’s stakeholders in finding out precautionary measures of improving
maternal health services among pregnant mothers in Bumbuli District Council. It
includes formulation of strategies, planning and guidelines of making maternal health
services more accessible among the pregnant mothers.
1.7 Scope of the Study
The study was an attempt to investigate the factors affecting utilisation of maternal
health care services among pregnant mothers in Bumbuli District Council using cross
sectional design, a sample of 110 participants aged between 15 – 49 years and
quantitative and qualitative techniques for data analysis
1.8 Organisation of Dissertation
The dissertation consists of five chapters. Chapter One presents an introduction
which includes background of the study, statement of the problem, objectives of the
study, justification of the study and scope of the study. Chapter two presents
Definition of key concepts, theoretical and empirical review of literatures. Chapter
three, presents methodology used in the study which further includes research design,
types of data and data sources, target population, study area, validity and reliability
of research instruments, data collection procedures and data analysis techniques.
Chapter four presents the findings and discussion, and finally Chapter five which is
made up of summary of findings, conclusion and recommendation.
9
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This chapter is an attempt to present definition of key concepts used in the study,
theoretical literatures and empirical literatures connected to the research problem as
well as the identification of the research gap which gives an insight of undertaking
this study. Whilst theoretical literatures gives a reviewed theories that explain
various factors affecting maternal health care services, an empirical literatures gives
analysis of the studies connected to the problem that have been undertaken by the
former researchers.
2.2 Definition of Key Concepts
This part presents the definitions of various concepts that are commonly used in the
study.
2.2.1 Maternal Health Care
Is the health of women during pregnancy, childbirth and the postpartum period. It
encompasses the health care dimensions of family planning, preconception, prenatal,
and postnatal care in order to reduce maternal morbidity and mortality (Phillippines,
2013)
2.2.2 Maternal Mortality
Is the death of a woman during pregnancy, childbirth or in the weeks after delivery,
the maternal causes that lead to death result from complications during pregnancy
and following birth most-maternal deaths result either from severe bleeding after
childbirth, infections, high-blood pressure during pregnancy or unsafe abortion,
(WHO, 2013).
2.2.3 Maternal Morbidity
Is the number of women with one more life threatening complication of pregnancy
during or within 42 days of pregnancy,(WHO,2012).
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2.2.4 Antenatal Care
This is the care receives from healthcare professionals during pregnancy. The
purpose is to monitor mother health, and baby's health to support them to make plans
which are right for their health,(Harrington,2012).
2.2.5 Postnatal Care
It is the attention given to the general mental and physical welfare of the mother and
infant. Care should be directed toward prevention, and early detection and treatment,
of complications and diseases include counselling, advice, and services on
breastfeeding, family planning, immunisation, and maternal nutrition (Boulvain,
2008).
2.2.6 Traditional Birth Attendant (TBA)
Sibley, Sipe and Koblinsky (2004) defines traditional birth attendant (TBA) as a
traditional midwife, community midwife or lay midwife who is able to provide
pregnancy and childbirth care. This definition will be used throughout this study to
mean the same
2.2.7 Born Before Arrival (BBA)
Is the phrase used by medical doctors when referring to the mother or pregnant
mother who give birth before arrival to hospital (King,Duthie, & Ma, 1992).
2.3 Theoretical Literature Review
In assessment of the factors affecting utilisation of maternal health care services
among pregnant mothers various theories were reviewed for purpose of getting
foundation of conducting this study.
2.3.1 Health Care Utilisation Theories and Models
In this section, two theories/models of health care utilisation are outlined. The
theories described are Andersen healthcare utilisation model and health belief model.
11
2.3.2 Andersen Healthcare Utilisation Model
Andersen healthcare utilisation model states that an individual's access to and use of
health services is considered to be a function of three interrelated factors (see Figure
2.1 below).
Predisposing factors: The socio-cultural characteristics of individuals that exist prior
to their illness. These according to Andersen includes: Firstly, social structure
including: education, occupation, ethnicity, social networks, social interactions, and
culture. Secondly, health beliefs which include: Attitudes, values, and knowledge
that people have concerning and towards the health care system, and lastly,
demographic factors including: age and gender.
Enabling factors: Enabling factors according to Andersen are the “logistical aspects
of obtaining care”. These are three in numbers. Firstly, personal/family: The means
and know how to access health services, income, health insurance, a regular source
of care, travel, extent and quality of social relationships. Secondly, community that is
available health personnel and facilities, and waiting time. Thirdly, possible
additions, including: genetic factors and psychological characteristic.
Need factors: These are the most immediate cause of health service use, from
functional and health problems that generate the need for health care services.
"Perceived need will better help to understand care-seeking and adherence to a
medical regimen, while evaluated need will be more closely related to the kind and
amount of treatment that will be provided after a patient has presented to a medical
care provider." (Andersen, 1995). This is divided into two, one is “perceived” that is
how people view their own general health and functional state, as well as how they
experience symptoms of illness, pain, and worries about their health and whether or
not they judge their problems to be of sufficient importance and magnitude to seek
professional help." (Andersen, 1995). Two is “evaluated” that is represents
professional judgment about people's health status and their need for medical care."
(Andersen, 1995).
12
Figure 2.1: Andersen Healthcare Utilisation Model
Source: Andersen (1995)
The model above fit exactly to this study which is about factors affecting utilisation
of maternal health care services among pregnant mothers at Bumbuli District Council
in Lushoto District, Tanga Region.
2.3.3 Health Belief Model (HBM)
The health belief model is a psychological health behaviour change model developed
to explain and predict health-related behaviours, particularly in regard to the uptake
of health services (Becker & Janz 1985) The health belief model was developed in
the 1950s by social psychologists at the U.S. Public Health Service (Becker & Janz ,
1985 and Rosenstock, 1974) and remains one of the best known and most widely
used theories in health behaviour research Carpenter (2010) and Glanz (2010). The
health belief model suggests that people's beliefs about health problems, perceived
benefits of action and barriers to action, and self-efficacy explain engagement (or
lack of engagement) in health-promoting behaviour Becker & Janz 1985) . A
stimulus, or cue to action, must also be present in order to trigger the health-
promoting behaviour (Glanz, 2010).
2.4 Empirical Literature Review
The factors affecting utilisation of maternal health care services has been
investigated by different researchers in different countries as well as in Tanzania.
Age
Gender
Ethnicity
PREDISPOSING
e.g. acculturation
NEED eg presence
Chronic condition
ENABLING e.g. education
HEALTH CARE
UTILIZATION
13
The studies employed different research designs and techniques research instruments
and data analysis techniques in their investigations. The results of these studies differ
accordingly.
2.5 Factors Influencing the Use or Non Use of Health Services
Tsawe et al (2015) noted that woman’s age has a significant influence on antenatal
and delivery services usage. Tsawe et al (2015) bivariate analysis revealed that
women aged forty and above use maternal healthcare services less than those
younger than forty. The bivariate analysis revealed that the use of institutional
deliveries decreases with age, whereas use of non-institutional deliveries increases
with woman’s age. Mostly young women use institutional deliveries compared to
adults.
For instance Simkhada (2008) investigated the factors affecting the utilisation of
antenatal care in developing countries using systematic review of literatures and both
quantitative and qualitative approach. The results revealed that maternal education,
husband’s education, marital status, household income, women’s occupation, media
exposure, cultural beliefs and ideas about pregnant were the most influencing factors
of antennal care use. Parity had a statistically significant negative effect on adequate
attendance. Whilst women of higher parity tend to use antenatal care less, there is
interaction with women’s age and religion.
2.6 Barriers of Utilising Maternal Health Care Services
A study conducted by Lubbock and Stephenson (2008) revealed that in most of the
developing countries health services are theoretically free, but indirect costs such as
financing travel to and from the clinic, leaving work to seek care, and paying for
prescribed medicines are considerable as barriers to accessing care and treatment.
Gage (2007) conducted similar study in Mali and cited the following barriers:
financial barrier was highly mention, distance from home to hospital and poor
customer care in health centers and hospitals coupled with rude languages from
nurses and doctors. Riaz, Zaidi and Khowaja (2015) outlined the following barriers
in utilisation of maternal health care services: cultural beliefs such as forbidding
women to the hospital for delivers “...delivery is a ‘normal process’ and there is no
14
need to go to a hospital” (Riaz, Zaidi and Khowaja, 2015). Others according to Riaz,
Zaidi and Khowaja (ibid ) are inadequate delivery health care supplies in hospitals.
However the study of Elo (1992), explored the hypothesis that formal education of
women influences the use of maternal health care services in Peru, mother’s
childhood place of residence, household socioeconomic status and access to health
care services. Both cross sectional and fixed – effects logic models were used for
analysis. The findings revealed a positive effect of maternal schooling on the use
prenatal care and delivery assistance.
In addition, large differentials were found in the utilisation of maternal health care
services by place of residence, suggesting that much greater efforts on the part of the
government are required if modern maternal health-care service are to reach women
in rural areas.
Falkingham (2004,) using survey data for Tajikistan, explored changes in the pattern
of maternal health care and the extent to which inequalities in access to that care
have emerged. In particular, the links between poverty and women's educational
status and the use of maternal health-care services were investigated. The survey
findings demonstrated a significant decline in the use of maternal health-care
services in Tajikistan since the country gained independence from the Soviet Union
in 1991. They show changes in the location of delivery and the person providing
assistance, with a clear shift away from giving birth in a medical facility toward
giving birth at home. Women from the poorest quintile are three times more likely
than women from the richest quintile to undergo a home delivery without a trained
assistant.
Parkhurst (2005,) conducted a comparative analysis on health systems factors
influencing maternal health services based on extensive case studies of maternal
health and health systems in Bangladesh, Russia, South Africa, and Uganda. A
number of cross-cutting health system characteristics affecting maternal health were
identified by comparing these diverse settings. The most important common systems
issues underlying maternal health care were found to be the human resource
structures, the public–private mix of service provision, and the changes involved
15
with health sector reforms. Systems issues were found to influence the access to and
utilisation of services, quality of care provided, and ultimately maternal health
outcomes.
Sebastian (2011,) investigated the factors affecting the use of maternal health care
services in Madhya Pradesh state of India. This study was designed as a cross
sectional study. Data from 15,782 ever married women aged 15-49 years residing in
Madhya Pradesh state of India who participated in the District Level Household and
Facility Survey 2007-08 were used for this study.
Multilevel logistic regression analysis was performed. The results of the study
showed that 61.7% of the respondents used antenatal care at least once during their
most recent pregnant whereas only 37.4% women received postnatal care within two
weeks of delivery. The household socio-economic status and mother’s education
were the most important factors associated with the use of antenatal care and skilled
attendance at delivery.
Aseweh, (2013) assessed the status of the maternal health services utilisation in
Ghana, aimed to examine the socio-economic factors influencing utilisation and
changes in utilisation of maternal health services over time. The results generally
identified age, education, access to health facilities, household wealth, residence,
ethnicity, geographical and religion as important socio-economic factors influencing
utilisation of maternal health services. Also, decomposition of changes in utilisation
showed that education, residence, accesses to health facilities together with others are
the most important contributors to inter-period changes in utilisation of maternal
health services.
Babalola (2014,) assessed the factors associated with utilisation of maternal health
services (MHS) among women giving birth in Haiti from 2007–2012 using
observational data derived from the 2012 Haiti Mortality, Morbidity and Service Use
Survey. Multilevel analytic methods were used to assess factors associated with use
of antenatal services and skilled birth attendance (SBA).The strongest adjusted
predictors include child’s birth rank, household poverty, and community media
saturation. Factors associated with use of maternal health service operate at multiple
16
levels. Efforts to promote such services should identify and pay special attention to
the needs of multifarious and uneducated women, address the distance-decay
phenomenon, and improve access for the poor. Community mobilisation efforts
designed to change norms hindering the use of MHS are also relevant.
Adam (2011), found that utilisation of maternal health care services (MHCS) varies
across the regions of Nigeria. Generally, women in the southern region are more
likely to utilise services compared to those in the north. There are differentials and
commonalities in the predictors of MHCS utilisation in the regions.
Education, family wealth index and place of residence are strong predictors of
service utilisation in all the regions. However, some factors are significant predictors
in one region but not in the other. These include employment in the northern region;
and mothers age and religion in the south. The study used an analytical ecological
study design which involved the analysis of secondary data from the 2008 National
Demographic and Health Survey to determine which socio-demographic factors
predict utilisation of maternal healthcare services (MHCS) in the different regions of
Nigeria.
Chimankar1 (2011,) investigated the factors influencing the Utilisation of Maternal
Health Care Services in Uttarakhand. The result revealed that the educational level of
women, birth order and wealth index are significant predictors in explaining ante-
natal and delivery care. Controlling the effect of other variables, the predictive power
of women’s educational level, wealth index has been positively associated with
antenatal care and also delivery care. Dataset of National Family Health Survey
conducted during 2005-06 was used for analysis. Both bivariate and multivariate
analyses were used in the study.
Dagne, (2010) assessed the role of socio-demographic factors on utilisation of
maternal health care services in Ethiopia: Umea University. Data was taken from the
2005 Ethiopian demographic and health survey which is a nationally representative
survey of women in the 15-49 years age groups. Then logistic regression technique
was used to estimate models of the outcome variables. The result showed that only
30% of the women received antenatal care while 11% received assistance during
17
delivery from health professional. Utilisation of these services was very low among
rural women as compared to those living in urban areas. Furthermore educational
status of the mother, household wealth, place of residence, birth order of the child
and educational and occupational status of the husband were found to be strong
indicators of utilisation in the total sample of women. In the urban women household
wealth, sex of household head and occupation of the husband had no effect on both
antenatal care and use of assistance during delivery. Birth order and sex of household
head were not significantly related with antenatal care use in the rural women and
education of the mother was not found to be significantly related with use of delivery
assistance in the rural sample.
In Tanzania few studies have been conducted to assess the factors affecting maternal
health services among pregnant mothers.
The study conducted by Mukong (2012), showed that socio economic factors such as
household income, maternal education, paternal education, Health knowledge as well
as distance to facility are positively associated with maternal health care utilisation in
Tanzania. Of the considered socio economic factors, maternal employment does not
have a significant influence on maternal health care utilisation. Concerning education
of parents, maternal education has proven to have a stronger influence on care use
relative to paternal education. On the other hand, full demand of prenatal care
services is less likely in households with more children, geographical variability and
among married women. However, postnatal care use is more likely among married
women and in households where both partners take decision regarding care seeking.
Shija (2001), found that, inadequate infrastructure, poor communication and
transport between health facilities and district hospital, inadequate number of skilled
personnel and irregular supplies of essential medicines and equipment make the
accessibility of this important intervention not possible to a greater number of
women. This study was conducted to investigate maternal health in fifty years of
Tanzania independence using cross sectional survey.
Mujinja, Tausi and Kida (2014) conducted a study on implications of health sector
reforms in Tanzania: policies, indicators and accessibility to health services. There is
18
still a gap on the demand side of the health system. The scarcity of health workers
and distribution bias of human resources remains a problem towards universal
coverage of maternal health care services. A good and workable human resources
management is lacking in the public health sector.
Gwamaka (2000) determined the factors that affect delivery in health facility among
recent delivered women. Materials and Methods: A cross sectional analytical study
was carried out among women with children less than two years prior to survey in
July 2012 in Nkasi district. Household survey using structured questionnaire was
used to collect information. The result revealed that socio – economic factors, social
cultural factors, social demographic characteristic, and health service factors were
affecting delivery in health facility among delivery women.
2.7 Improving Utilisation of Maternal Health Care Services
Mekonnen and Mekonnen (2002) conducted study on how maternal health care
services can be improved and listed the following strategies: improvement of
accessibility and improvement of awareness of such services. Shija (2001) on the
other hands noted that a need of making sure that skilled doctors on maternity cares
are available in all health centres in Tanzania. Adda (2000) calls upon stake holders
to formulate health programmes to help local governments and civil society
organisations to deliver high-quality, rights-based, and sustainable maternal and
reproductive health services that will address the specific needs and priorities of their
communities especially those of the most marginalized and vulnerable groups.
2.8 Summary of Literatures and Study Conceptualising.
Even though various studies have been undertaken to investigate the factors affecting
utilisation of maternal health services, still the results are not the same. For instance
Shija (2001), found that, inadequate infrastructure, poor communication and
transport between health facilities and district hospital, inadequate number of skilled
personnel and irregular supplies of essential medicines and equipment make the
accessibility of this important intervention not possible to a greater number of
women. However Mujinja, Tausi and Kida (2014), found that scarcity of health
19
workers and distribution bias of human resources remains a problem towards
universal coverage of maternal health care services.
A good and workable human resources management is lacking in the public health
sector. Olayinka (2014), found that the major variables associated with barriers to
utilisation of maternal health services among respondents were poor knowledge of
the existing services, previous bad obstetric history; attitude of the health care
provider, availability, accessibility and husband's acceptance of the maternal
healthcare services.
The reviewed empirical studies above are characterised by differences in findings
These differences might be due to differences in objectives of the studies, research
methodologies including research designs, target population, sampling techniques,
procedures and instruments of collecting data. Furthermore, the different in findings
might be due to the use of different data analysis techniques.
As far as Bumbuli District Council is concerned, there is not study to determine the
factors that affect the utilisation of maternal health care services among pregnant
mothers has been conducted there despite the fact that there are problems in maternal
health service. Therefore, this study was designed to address the gap with the aim of
assessing the factors affecting maternal health services among pregnant mothers and
suggest the measures that have to be taken to make maternal health care services
more accessible among women.
2.9 Conceptual Framework
A conceptual framework is a model of presentation where a researcher represents the
relationships between variables in the study and shows the relationship graphically or
diagrammatically (Orodho,2004). Basing on theoretical and empirical literature
review, the conceptual framework was formulated as illustrated in Figure 2.2 as
follows;
20
Figure 2.2: The Relationship between the Variables under Consideration
Source: Researcher, 2015
Figure 2.2 shows the relationship between various factors and maternal health
services. The variables used for analysis were selected basing on theoretical
framework and prior empirical studies as well as the aim of the study and availability
of data. Social - demographic factors including level of education, Mother’s
occupation, Household Wealth, Age of the mother, family ties were assumed to
affect utilisation of maternal health services through awareness and recognition of
availability of service and acceptability of service. These determine awareness and
recognition of availability of service and acceptability of service. Thus low
awareness on the role of maternal health care services and ability to acquire those
services lead to low utilisation of health care services. However Cultural beliefs and
practice which includes cultural norms, ethics and beliefs influence attitudes towards
maternal health care services provided in hospitals and health centres. Moreover
negative attitude towards maternal health care provided in hospitals and health
centres often lead to self-care, home remedies and consultation with traditional
healers in rural communities hence resulting in low utilisation of maternal health care
services provided in hospital and health centres.
Utilisation of maternal
health care services
Attendance to antenatal
service, delivery through
MHCS
Social-demographic factors
education, occupation, income, age,
distance
Cultural beliefs and practices
norm, measure of confidence and
power, trust, fear for operation
Health system factors
Availability of health facilities,
payment for service, customer care
service
21
Furthermore, health system factors including inadequate human resource, shortage of
health facilities, and payment for health service might affect maternal health care
services by discouraging attendance of women in getting health services.
22
CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
This chapter is an explanation of the procedures and methods that were used in
undertaking the study. The discussion of the chapter is focused on the research
design, study area, target population, sample and sampling techniques, data
collection methods, validity and reliability of research instruments and data
collection procedures and its analysis.
3.2 Type of the Study and Research Design
The type of the study was both qualitative and quantitative. The study was qualitative
because some of the information given by the respondents were related to their
attitudes and motivation on the utilisation of the maternal health care service. On the
other hand, the quantitative data included the information which were in continuous
in nature.
According to Kothari (2004) the design refers to an outline of what the researcher
will do from writing the hypothesis and its operational implications to the final
analysis of data. The cross-sectional survey method gathers data from a relatively
large number of cases at a particular time. Thus the respondents selected should be as
representative of the total population as possible in order to produce a miniature
cross-section (Kothari, 2004). The study employed a community based cross –
sectional survey design in the assessment of the factors affecting utilisation of
maternal health care services among pregnant mothers in three wards of Bumbuli
District council. This design was appropriate as it enabled a researcher to collect
primary data from different wards of Bumbuli District council at a time.
3.3 Study Area
The study was conducted in Bumbuli District council which is the new council of
Lushoto District council established in 2013 located in Tanga region. Bumbuli
District council is situated in Lushoto district located geographically at 4° 52' 0"
23
South, 38° 28' 0" east. Administratively, Bumbuli constitutes 16 wards. The wards
are named Dule, Nkongoi, Baga, Bumbuli, Funta, Mamba, Mayo, Mbuzii, Mgwashi,
Milingano, Mponde, Soni, Tamota, Vuga, Mahezangulu, and Usambara. Bumbuli is
the most densely populated constituency in Lushoto district. It has an estimated
population density of 309 people per square kilometer.
According to the 2012 Tanzania National Census, the population of the Lushoto
District was 492,441 for which male were 230,236 and female were
262,205,population of Bumbuli District Council was 160,005 for male were 76,389
and female were 83,616, The choice of the council was determined by the interaction
that the researcher had with pregnant mothers in the course of provision of health
services in the council that reflected low utilisation of maternal health care service
among pregnant mothers. In addition, the familiarity of the researcher with the study
area also made it easy for her to develop immediate connection with the respondents
hence making the data collection more manageable.
3.4 Study Population
The targeted population for the study was all women aged between 15 – 49 years old
who gave birth between January 2012 and December 2014. Although the women
aged between 15 and 18 years old seem young, they were considered in the study
because of the real situation in the rural areas of Tanzania as they always get
pregnancy termed as early child birth and early marriage i.e. the population selected
is at reproductive age. The women aged between 15 – 49 years was considered to be
the most concerned pregnancy receivers and deliverers group that plays role in
utilisation of maternal health care services.
3.5 Units of Analysis
The unit of analysis is the major entity that is being analysed in a study. It is the
'what' or 'who' that is being studied. In social science research, typical units of
analysis include individuals (most common), groups, social organisations and social
artifacts (Spring, 1993)
24
3.6 Variables and their Measurements
This study has two main variables: independent and dependent variables. The
independent variable include socio-demographic factors, healthy system factors and
cultural beliefs and practices factors while the dependent variable include attendance
to antenatal service and delivery through MHCS.
The measurement of socio-demographic variable: age measured in years
(continuous); income measured in terms of amount in Tshs. generated per day
(continuous); distance was measured in kilometers from home to the facility with
MHCS (continuous); and occupation measured in type of job engaged-peasant, self-
employed, employed, business (categorical).
The measurement of healthy system variable: health facility availability was
measured in presence and quality of the facilities with the scale of YES/NO
(categorical); payment for service was measured in ability to pay with the scale of
YES/NO (categorical); customer care service was measured in language used by the
human resource of the facility (soft/harsh) with scale of YES/NO (categorical);
readiness to attend the pregnant mother on time with the scale YES/NO (categorical).
The measurement of cultural beliefs and practices: norms were measured in terms
perception of delivery at home or in the facility i.e. delivery at home is perceived as
power and confidence of the pregnant mother; trust to the TBA than professionals;
fear for operation especially when delivery through MHCS (all being categorical).
The measurement of the utilisation of MHCS: attendance to antenatal service was
measured in having the clinic card with YES/NO (categorical); dates attended
(continuous); knowledge of service content provided at the clinic (categorical) while
the delivery through MHCS was measured in terms of date delivered in the clinic
card (continuous); having birth supporting permit given always in order to be given
the birth certificate from the district council.
3.7 Sample Size and Sampling Techniques
This study used stratified random sampling technique and purposive sampling
technique designs. A sample was chosen from three wards namely Soni, Bumbuli
25
and Tamota. In the second stage, a sample of respondents (reproductive women)
within selected wards was obtained. These respondents were considered because they
were characterized as they are still reproductive hence in the category of benefiting
from the utilisation of the maternal health care service. On the other hand, purposive
sampling was used to sample the facility healthy workers (nurse) due her position
hence was able to provide the required information.
Based on the data which consists of the participate from Bumbuli District Council,
the distribution of three wards are as follows: 12,839 (SONI), 10,159 (BUMBULI)
and 8,300 (TAMOTA). The total population therefore is 31,298 of women. The
formula (Kothari, 2004) below was used to calculate the sample size as:
Z2
pqN
n = ___________________
e2
(N-1) + Z2
pq
Whereas:
n: the sample size for a finite population
N: size of population which is the number of respondents (31,298)
p: population reliability (or frequency estimated for a sample of size n), where p is
0.5 which is taken for all developing countries population and p + q= 1
e: margin of error considered is 9% for this study
Z α/2: normal reduced variable at 0.05 level of significance z is 1.96
According to the above formula, the sample size for this study is:
26
(1.96)2
0.5x0.5x31,298
n = ____________________________
(0.09)2
(31,298-1) + (1.96)2
x0.05x0.05
(1.96)20.5x0.5x31,298
n = ____________________________
(0.09)2
(31,298-1) + (1.96)2
x0.05x0.05
30058.5992
n = ____________________________
254.4661
= 118.124179
The expected minimum sample size for the study was 118 respondents.
3.8 Types and Sources of Data
The study utilised both primary and secondary data. Secondary data were collected
from various reviewed literatures (books, journals, reports, papers, newspapers,
dissertations TV and Radio programs) related analysis of the factors affecting the
utilisation of pregnant mothers in Bumbuli District council. On the other hand,
primary data were collected from the questionnaires, interview and through the
focused group discussions. The primary data are those which are collected a fresh
and for the first time and thus happen to be original in character (Kothari, 2004)
3.9 Data Collection Methods
The researcher used questionnaires and interview research instruments to collect data
from 110 women aged between 15 – 49 years, Questionnaires were chosen because
of their ability to gather a lot of information at a time while the interview schedules
were used to obtain a detailed information that would complement the information
gathered through the questionnaire. The interview was necessary because of its
flexibility the researcher had an opportunity of rephrasing the questions to enhance
27
understanding among the respondents and hence get relevant answer. Interview also
helped in asking follow-up questions during the session.
3.9.1 Structured Questionnaire
According to Polit and Hunger (1997:334) a structured questionnaire is a data
collection instrument that encompasses a set of questions or items in which phrasing
of both the question and answer alternatives are encoded. The respondents either
complete the instrument themselves in a paper-and-pencil format or an interviewer
asks questions orally but relies on the respondents to answer others in writing.
Katzellenbogen et al (2002:82). In this study the respondents were given the
questionnaire to fill in at their own time and the researcher went to collect the filled
in copies of questionnaires after an agreed duration.
3.9.2 Interview Guide Questions
In - depth interviews were conducted with women that had delivered at home in the
period January 2012 to December 2014. Face to face in - depth interview was
conducted using interview guide questions. Respondents were asked how they
perceived the care they received from health workers before, during and after
delivery.
3.10 Validity and Reliability
According to Kothari (2004), validity is the extent to which differences found with a
measuring instrument reflect true differences among those being tested. Validity is
the most critical criterion and indicates the degree to which an instrument measures
what it is supposed to measure. Validity can also be thought of as utility.
To enhance validity of instruments pre-testing was done to verify whether the
questions were acceptable, answerable and well understood. The feedback from pre-
testing was used to improve the instrument prior to the commencement of fully-
fledged study. This process was necessary for the sake of collecting the information
that was relevant to this study in order to get the picture of the problem and hence
make plausible recommendation.
28
Reliability is the consistency of the research instrument. It is a measure of degree to
which a research will yield consistent results after repeated trials. The test of
reliability is another important test of sound measurement. A measuring instrument is
reliable if it provides consistent results. Reliable measuring instrument does
contribute to validity, but a reliable instrument need not be a valid instrument
(Kothari, 2004) but a valid instrument is always reliable. To ensure reliability, the
research instruments were pre - tested and the feedback of each trial was compared to
confirm if the results of trials are consistent. The aim of pretesting was to ensure that
the research instruments contained internal consistency where all questions could
gather the anticipated information and not otherwise. During pre-testing, the
questions that could collect irrelevant information were replaced by relevant ones to
enhance the quality of research instruments.
After the researcher’s visit to the sampled health centres to notify and familiarise
herself with the location of the health centres and arranging the dates for
administering the instruments, the questionnaires were distributed and administered
to the women of 15 - 49 years old. The respondents were given a sufficient time to
read the questionnaires in order to understand and provide the corresponding
answers. Face to face in - depth interview was conducted using interview guide
questions.
3.11 Data Analysis Methods
Both quantitative and qualitative techniques were used to analyse data to
complement the weakness of one another. Under quantitative techniques the data was
processed and analysed using Statistical Package for Social Science (SPSS) version
20. Data processing involved editing, coding, classification and tabulation of
collected data so that they became easy to control for analysis. Descriptive statistics
such as percentages were used to analyse the variables under study. Association
between predictors and mothers accessing antenatal care was analysed by Pearson
chi-square test at 95% confidence level.
29
3.12 Ethical Consideration
For the purpose of data collection, letters of introduction from Mzumbe University
was obtained and submitted to District Medical officer of Bumbuli. Thereafter the
researcher visited to the sampled health centres to notify and familiarise herself with
the location of the health centres and to arrange for the dates for administering the
research instruments.
The researcher sought the respondents’ consent before including them in the study.
In so doing the researcher provided the respondents with the information concerning
the purpose of the study. The respondents were also told that they were free to decide
to participate or not and that they could decide to withdraw from the interview at any
time they wanted. Confidentiality of the collected information was assured to the
respondents. The questionnaires were numbered instead of using respondent’s name
to assure the respondents that the collected information would be confidential and no
one else except the researcher would have access to the raw data.
30
CHAPTER FOUR
PRESENTATION OF FINDINGS AND DISCUSSION
4.1 Introduction
This chapter presents the findings and discussion on factors affecting utilisation of
maternal health care services among pregnant mothers. These chapter is divided into
five parts: introduction, respondents social demographic factors, social –
demographic factors affecting utilisation of maternal health care services among
pregnant mothers, cultural beliefs and practices effecting utilisation of maternal
health care services among pregnant mothers and ways through which health
systems affect utilisation of maternal health care services among pregnant mothers in
Bumbuli District council.
Although the study aimed to survey the 118 respondents, only 110 were accessed
during the field work. The reasons for failing to access all the sampled population
was due to the reluctance of some respondents, shortage of time, wrongly answered
questionnaires. The sample size after the field work was 110 respondents.
4.2 Respondents Social Demographic Factors
During fieldwork, data concerning social-demographic characteristics of the
respondents were collected. The respondent’s characteristics provided the basis for
interpreting the findings on determining factors affecting utilisation of maternal
health care services among pregnant mothers in Bumbuli District Council.
A total of 110 reproductive women with the age ranging between 15-49 years old
were enrolled in the study during the field survey. Table 4.1 shows that 14.5% of the
respondents were within ages 15-20, this is early child bearing which is among the
risk factor for maternal mortality. Majority (34.5%) of respondents in this study
were of the age group 26-30 years. On the other hand, the proportion of respondents
between ages 36-40 years were 18.0% and 20.0% were between ages 21-25 years,
2.1% age of group 41-45 years, whereas only 3.6% of the respondents were in age
46-49 years. This implies that, most of the respondents are still energetic and hence
will continue in need of MHCS.
31
Table 4.1 also shows that 66.4% of the respondents were married at the time of the
survey, about 20% were single and 13.6% were separated. Conversely none of the
respondents in this study was reported to be widowed. The results indicate that, most
of the women utilising the MHCS are married.
Concerning respondent’s education this study revealed that, over half (51.8%) of the
respondents attained some primary education. Respondents with secondary and post-
secondary education level were 14.5% and 1.8% respectively. On the other hand,
only 0.9% reported to attain adult education. Furthermore majority (47.3%) of
women participated in this study were peasants. About 20% were involved in
business, 16.4% were employed and 16.4 % were self-employed (Table 4.1). the
findings it is noted that, the women are not utilising the MHCS because of their
education level of which more than 50% have primary education level.
The findings indicate that, the occupation of respondents was peasant (47.3%),
business (20%), employed (16.4%), self-employed (16.4%). The results show that,
most of the respondents were peasant hence the utilization of MHCS might be poor
to them as most of their time is farming involvement and have no time to learn about
MHCS.
This finding was consistent with the findings of the study conducted by Adam
(2011), Babalola (2014), Aseweh (2013), Sebastian (2011), Navaneethan (2008) and
Gwamaka (2000) that found these socio – demographic factors as the main predictors
of the utilisation of maternal health care services.
32
Table 4.1. Respondent’s Socio-Demographic Factors
Variable
Frequency
Percentage
Age group
15-20 Years 16 14.5
21-25 Years 22 20.0
26-30 Years 36 34.5
31-35 Years 8 7.2
36-40 Years
41-45 Years
22
2
18
2.1
46-49 Years 4 3.6
Marital Status
Single 22 20.0
Separated 15 13.6
Married 73 66.4
Education level
No formal education 34 30.9
Primary education 57 51.8
Secondary education 16 14.5
Post-secondary education 2 1.8
Adult education 1 0.9
Occupation
Peasant 52 47.3
Business 22 20.0
Employed 18 16.4
Self employed 18 16.4
Source: Fieldwork 2015
4.3 Social-Demographic Factors Affecting Utilisation of Maternal Health Care.
Table 4.2 revealed that majority of women (97.3%) who were married attended
antenatal clinic in their last pregnancy compared to 2.7% who did not attend
antenatal clinic in their last pregnancy. 27.3% of women who marital status were
single at the time of survey said they didn’t attend antenatal clinics in the previous
pregnancy. The marital statuses affect therefore the attendance of clinic e.g. married
women attendant more clinic than the unmarried ones.
From the same table, it is realised occupation was affect attending antenatal clinic in
their previous antenatal clinic. In this aspect, the peasant do not attend to the clinic
compare to women of other occupations like employed, self-employed and business.
This finding concur with a study conducted in West Africa which shows that marital
status was also an influencing factor affecting utilisation of maternal health care
services among pregnant mothers, They found that divorcees and widows chose to
deliver at home (Envuladu E et al 2013).
33
Distance from health facilities was found to be the factor affecting mothers attending
antenatal clinic. Findings show that 25% of women who reported to reside 3 to 4
kilometers from health facilities did not attend antenatal clinic in their previous
pregnancy. The ones nearby the facility attend to the clinic than those living far away
from the clinic.
Respondents were asked whether they attended antenatal clinic in their last
pregnancy in association with their occupation, all respondents who were employed,
doing business and self-employed attended antenatal clinic in their last pregnancy,
while 44.4% of women who said they were peasants did not attend antenatal clinic in
their last pregnancy, Among women who were peasant 55.6% attended antenatal
clinics in their last pregnancy. In previous studies conducted in other parts of Sub-
Saharan Africa, Demographic and socioeconomic variables such as occupation of
mother and husband were found to be strongly related to maternal health care
services utilisation (Adekanle 2011,).
Women’s utilisation of maternal health care services is influenced by many factors
including distance to health facility, prior experience attending antenatal care,
household income and individual mother perceptions regarding maternal care. A
finding from this study shows that, marital status was significantly associated with
whether mother attended antenatal clinic in the last pregnancy.
34
Table 4.2: Association between Social-demographic Factors and Mothers
Attendance to Antenatal Clinic
Yes No
Single 72 (72.7%) 6 (27.3%) 22 (100%)
Separated 15 (100%) 0 (0%) 15 (100%)
Married 71 (97.3%) 2 (2.7%) 73 (100%)
102 (92.7%) 8 (7.3%) 110 (100%)
Peasant 10(55.6%) 8(44.4%) 18(100%)
Business 22 (100%) 0 (0%) 22 (100%)
Employed 18 (100%) 0 (0%) 18 (100%)
Self employed 52(100%) 0(0%) 52(100%)
102 (92.7%) 8 (7.3%) 110 (100%)
Less than 1 km 38 (100%) 0 (0%) 38 (100%)
1 – 2 Kms 38 (100%) 0 (0%) 38 (100%)
3 – 4 Kms 24 (75%) 8 (25%) 32 (100%)
Over 5 Kms 2 (100%) 0 (0%) 2 (100%)
102 (92.7%) 8 (7.3%) 110 (100%)
1000-1999Tsh 46 (100%) 0 (0%) 46 (100%)
2000-5000Tsh 14 (100%) 0 (100%) 14 (100%)
Above 5000Tsh 42 (84%) 8 (16%) 50 (100%)
102 (92.7%) 8 (7.3%) 110 (100%)
Household income
Total
Total
Distance from health
facility
Total
Occupation of respondent
Variables
Whether or not attended antenatal
clinic in the last pregnancyTotal
Marital Status
Total
Source: Fieldwork 2015
All women who participated in this research study were asked about their place of
delivery for the last delivery and the result are shown in Figure 4.1 The results reveal
that, 37.5% of the deliveries took place at traditional birth attendant centres (TBA).
22.9% delivered at home, and only 18.8% of deliveries took place at Public hospitals
and 20.8 % took place at private clinics. This means that, the delivery in Bumbuli is
mostly done at TBA.
35
Figure 4.1: Percentage distribution of women by Place of delivery
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
At home At a Traditionalbirth attendant
(TBA)
Public Clinic Private Clinic
Per
cen
tage
Place of delivery
Source: Fieldwork 2015
Findings from this study also shows that home deliveries were higher among women
who were single (54.5 %%) compared to respondents who were married (27.3%) at
the time of survey. Socio-demographic factors (Marital status, occupation and
distance from health facility) have influence on women’s choice of place of deliver.
The results further reveal that 37.5% of the deliveries took place at traditional birth
attendant centres (TBA). 22.9% delivered at home and only 18.8% of deliveries were
took place at Public hospitals and 20.8 % took place at private clinics.
The proportion of home deliveries (54.5%) was higher among women of age 21-25
years of age at the time of survey. These findings show that 48.0% of women aged
26-30 years delivered at traditional birth attendants. Health system, cultural beliefs
and practices and Social – demographic variables such as occupation of mother and
husband were found to be strongly related to maternal health care services utilisation.
36
Table 4.3: Socio-demographic characteristics and choice of a place of delivery
Variables
Place of delivery
At home (TBA)
public
Clinic
private
Clinic Significance level
Age
15-20 Years 4(18.2%) 12(24%) 0(0%) 0(0%)
21-25 Years 12(54.5%) 4(8.0%) 4(6%) 2(10.0%)
26-30 Years 2(9.1%) 24(48.0%) 6(33.3%) 6(30.0%)
31-35 Years 0(0.0%) 0(0.0%) 6(33.3%) 2(10.0%) p=0.000
36-40 Years 4(18.2%) 10(20.0%) 2(11.1%) 6(30.0%)
46-49 Years 0(0.0%) 0(0.0%) 0(0.0%) 4(20.0%)
Marital status
Single 12 (54.5%) 10 (20%) 0(0%) 0(0%)
Separated 4 (18.2%) 11(22.0%) 0(0%) 0(0%) p=0.000
Married 6 (27.3%) 29 (58%) 18(100%) 20(100%)
Occupation
Peasant 8 (36.4%) 24(48%) 2(11.1%) 18(90%)
Business 0 (0%) 12 (24%) 10 (55.6%) 0(0%)
Employed 6 (27.3%) 4 (8%) 6 (33.3%) 2(10%) p=0.000
Self employed 8 (36.4%) 10 (20%) 0 (0%) 0(%)
Time to reach
the nearest
health
facilities
Less than 1
hour
4(18.2%) 24(48.0%) 10(55.6%) 14(70%)
1 – 2 hours 6(27.3%) 10(20%) 8(44.4%) 4(20%) p=0.002
3 – 4 hours 12(54.5%) 14(28%) 0(0%) 2(10%)
Over 5 hours 0(0%) 2(4%) 0(0%) 1(7%)
Source: Fieldwork 2015
Table 4.4 shows, among the mothers who participated in this study, about 9.1%
visited antenatal clinic four times. 10.9% visited only once over the pregnancy
period. Among the mothers who participated in this study 14.5% and 16.4% visited
the health facilities for antenatal care two and three times before delivery. These
findings suggest that women of reproductive age in the study area are not well
utilising initial antenatal care services, At the initial antenatal care visit and with the
aid of a special booking checklist the pregnant women become classified into either
normal risk or high risk.
37
Table 4.4: Frequency of antenatal clinic visits in the last pregnancy among
respondents
Frequency of antenatal clinic visits
in the last pregnancy Frequency (n=110) Percentage
Never 7 6.9
Once 12 10.9
Twice 16 14.5
Thrice 18 16.4
Four times 47 42.7
Over 4 times 10 9.1
Source: Fieldwork 2015
Respondents were asked if they happen to pay for the antenatal care services
provided, majority (89%) said they didn’t pay for the service, while 11% of the
respondents said they incurred some costs to get the services (Figure 4.1). Among the
mothers who said they had to incur some expenses in getting the antenatal care
services, 33.3% of them noted that they use the money for buying gloves and 66.7%
said they had to pay for staff allowances such as call allowances and transport
allowances.
Figure 4.1: Whether or not respondents pay for ante-natal services
Source: Fieldwork 2015
38
Figure 4.2 Type of Cost Incurred Seeking Maternal Care Among Study
Participants
Source: Fieldwork 2015
Despite the Tanzania’s government’s commitment to universal provision of free
maternal health services, this study found that nearly 11% of women who delivered
in a facility in a Bumbuli District council reported paying for delivery. For those
respondents who were mentioned to have incurred some costs for maternal care
services, majority said they were to pay the staff for allowances and 33% were
buying gloves. Furthermore the qualitative study revealed that there are many hidden
costs during delivery a mother has to incur, and when the money is not enough this
has been always big barrier utilising maternal health services. This finding is
consistent with the finding of the study conducted by Simkhada (2008), Navaneethan
(2000), Parkahurst (2005) and Gwamaka (2000) that investigated the effect of health
systems including costs of delivery on utilisation of health care services.
These are interviews from respondents which are reported that labor started at night.
Some of them started off for the health facility but delivered in transit under the
assistance of the TBA, while others stayed and delivered in their homes.
39
One of the interviewee from Soni Ward aged 28 had the following remarks to make:
“…As we were walking on the way…. I could not proceed
because I failed to walk. Then one of the women who were
escorting me called the Traditional Birth Attendant (TBA). They
told her that we were on our way to the clinic and I was on the
roadside. As soon as she arrived she assisted me delivered the
baby”.
Another participant aged 23 said, she went to TBA because she had difficulties in
walking and TBA was closer than a health facility. She could not walk because she
had a swollen leg, and had rapid progress of labor. Although women had positive
attitudes towards giving birth in health centers, they often encountered barriers
reaching facilities. Geographical factors were among the barriers towards reaching
health facilities.
One of the respondents who was involved in an in depth interview ( a woman of 26
years from Soni) had the following remarks:
“… I was forced by circumstances to deliver my baby at home
because the only health centre we depend on is far away from
home. Another coincidence is that it was during rainy season and
therefore I was not able to reach the health centre.
These results suggest that birth-preparedness and complication readiness is a
comprehensive strategy to improve the use of antenatal care services available thus if
well implemented maternal mortality can be decreased. Birth-preparedness and
complication readiness include many elements, such as; knowledge of danger signs;
plan for where to give birth; plan for a birth attendant; plan for transportation; and
plan for saving money.
The researcher conducted an interview with a woman of 27 years from Soni who had
the following comments to make:
40
“… I prefer home delivery to hospital delivery because Traditional
Birth Attendants are very ethical in the sense that they are very
confidential. Unlike some nurses and doctors who have tendencies of
leaking or exposing their patients sickness to the public. For
example we pregnant mothers are afraid of going to hospital
because when doctors discover that you are HIV positive they have
tendency of leaking such information to the public. These and other
reasons normally keep us away from hospitals for delivery”
The above response corresponds with two variable in the conceptual
framework which are beliefs and ethics. These findings are supported by those
Gage (2007) who conducted similar study in Mali and noted that in hospitals
there is poor customer care coupled with rude languages from nurses and
doctors who are also not ethical.
4.4 Delay in Assisting Maternal Patients
In order to get information on the promptness of maternal health services, the
researcher interviewed one of the respondents from Bumbuli Ward. The
respondent had the following complaints to make:
“… when I arrived at the health center I was not attended
promptly. The doctors and nurses were just looking at me as if
I am not in pain. The Traditional Birth Attendant who
accompanied me to the health centre was puzzled the way in
which health service workers treated me and she started
responding to them in a cruel manner. She said these health
workers are very boastful and inhuman. This is why we resort
to the TBA.She continued saying that the TBAs are very
sympathetic and have sense of human and some of them are
our relatives. This is one of the reasons why we go to the
TBAs.”
The findings above shows that women have no confidence to that health centre
workers. One of the reasons is that they delay in attending them and also they
do not maintained confidentiality. The TBAs are very willing to help and they
are very secretive about what happened during delivery. These findings
concurs with those of Lily, Bjune, and Øyvind (2013) who noted that reported
mothers who are assisted by TBA are normally well received compared to
those who deliver at hospitals or health centres.
41
4.5 Reasons for Choice of Place of Delivery
During the study, the mothers interviewed were asked where they had planned to
deliver; a woman from Tamota had the following experiences:
“… I do not see the reasons to go to the health centres as they are far
away from my home place. Traditional Birth Attendants are plenty in
my place why should I go far. I have three children, all of them I was
assisted by TBAs in my village. Some of the nurse and doctors
normally rush women to the theater for operation, I am very much
afraid to be operated. What I can say is that the TBAs are
knowledgeable and they know what they are doing”
The findings indicate that pregnant mothers especially from rural areas have no faith
with hospital delivery. This is likely an indication of facts that education and
awareness on the benefits of hospital delivery are not known to them. Surprisingly
enough the response from Tamota woman seems to correspond to the study by
Akinyo (2009) who noted that nurses are said to be rude as compared to TBAs who
are generally friendly. Because of the trust built in a TBA, mothers in the rural area
prefer them to health workers. “Some of these TBA had even managed to handle
deliveries that are breech and difficult, and yet some nurses send labouring mothers
to theatre so quickly. This scared them from health unit delivery (Akinyo, 2009).”
4.6 Health Systems and Utilization of Maternal Health Care Services Among
Pregnant Mothers in Bumbuli District Council.
All respondent participated in this study were asked whether or not paid for delivery
services. Despite the Tanzanian government’s commitment to universal provision of
free maternal health services, this study found that nearly 11% of women who
delivered in a facility in a Bumbuli District Council reported paying for delivery. In
an effort to reduce maternal mortality, like several other governments in developing
countries, Tanzania’s government has declared maternal and child health services,
including facility delivery, to be exempt from user fees in government facilities, this
is according to United Republic of Tanzania Ministry of Health (2003).
To supplement above information, the researcher interviewed a woman from Tamota
on whether they pay for delivery services or not. The following are the remarks
which she made:
42
“...I heard from the radio that delivery services for the government
health facilities are free of charge but when I went to the health
facility for delivery I was asked to buy gloves and other facilities.
This puzzled me a lot”
The researcher had also to interview one of the nurses in Bumbuli Ward as to why
they charge women for delivery services. The nurse had the following to say:
“... It true that delivery services are free of charge in all government
owned health facilities but sometimes such facilities tend to run out of
stock. I think it is wise to tell a pregnant mother to buy such facilities
when they are out of stock rather than telling her we cannot be able to
help you. We normally do that for the sake of serving the life of such
mothers and their babies and not otherwise”
The choice of place of delivery was not only determined by income. The qualitative
data and researcher observations during fieldwork revealed that quality of services
was perceived to play a major role in choice of place of delivery. Although some
government health facilities were equally close to where a majority of women lived,
and were free of charge, some women decided to go to more distant private health
facilities, despite the user charges involved. The researcher conducted two FGDs, the
participants said that they were asked to bring water to clean the labour ward after
delivery.
“…I decided to deliver in that private health facility (X) because they provide
good services. They are empathetic and can solve any problem; they have a
car and can probably take you to the next level of services if need
arises………. In addition they don't ask you to bring water “
4.7 Cultural Beliefs and Practices and Utilization of MHCS
These were also explored through interview whether cultural beliefs and utilisation
of MHCS. In so doing, it was realized that, women do not utilize the MHCS because
of beliefs such as lack of confidence and power when deliver through the service,
fear of operation through the service, believing in the natural medicine than the
modern medicine, and trusting of the TBA than the professional ones.
‘We always decide to deliver at home because if one deliver at home than at the
facility, she seems confident and powerful” One respondent said
‘I afraid to be going to deliver at the facility as I afraid to be operated rather waiting
to deliver in the normal way” Another respondent said
43
CHAPTER FIVE
SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction
This chapter presents summary of findings, conclusion and recommendations. While
summary of findings is an attempt to briefly review the results obtained in data
analysis as in detail explained in chapter four, conclusion and recommendations
present a winding up of the whole dissertation and suggest measures to improve
maternal health care services in Bumbuli District Council respectively.
5.2 Summary of Findings
This study investigated factors that affect utilisation of maternal health care services
among pregnant mothers at Bumbuli District Council Lushoto District. This part
summarizes the research findings as analysed and presented in chapter four regarding
the research questions that guided the study. It was summarily found that, the socio-
demographic factors affect the MHCS. For example, married women utilise the
MHCS more than the unmarried ones.
Additionally, it was noted that, the healthy system was another factor affecting the
utilization of MHCS. For example, payment ability of the service is the major factor
that bars the utilization of the service by the women in Bumbuli District Council.
Furthermore, the findings of the study indicate that, cultural beliefs and practices also
influence the utilization of the MHCS in Bumbuli District Council among the
reproductive women. For example, the fear of being operated at the facility,
traditional confidence and power trust on TBA.
5.3 Conclusion
This study concludes that, the factors such as socio-demographic, healthy system and
cultural beliefs and practices affect the utilisation of MHCS. Factors influencing
maternal health services utilisation operate at various levels - individual, household,
community and state. While education, socio-economic level, and urban residence
are consistently strong predictors of all the maternal health services considered in
44
this study, Perception of mothers to the quality of services provided was the other
factor influencing the use of services. This was because of absence of adequate
information about the services provided in the health centres. Distance from
residential areas to the health centres was highly cited as the reasons for pregnant
mothers to prefer home delivery to assisted by TBA. The TBAs were considered
very willing to help and very secretive about what happened during delivery.
Other determinants of service utilisation generally vary in magnitude and level of
significance by the type of maternal service - ante-natal care, skilled attendant at
birth, and postnatal care. To be optimally effective, interventions to promote
maternal health service utilisation need to take these findings into consideration: they
should target the underlying individual, household, community and state-level factors
that are relevant to each type of maternal health service. It was particularly important
for interventions to explore effective ways of increasing service utilisation among
lowly educated and poor women in rural areas who are the least likely to use
maternal health services.
5.4 Recommendations
Based on the findings and conclusion of the study, the following recommendations of
improving the provision of health care services with regards to the findings obtained
were made by a researcher:
5.4.1 Regarding Health System on utilisation of Maternal Health Care Services.
Since the unmarried, uneducated, peasant and aged 15-20 years old women do not
utilize the MHCS compare to the opposite, the government and NGOs should
introduce alternative ways of reaching (e.g. education and sensitisation house to
house) such women in order to make them full utilising the service for their benefits
and future generation reproduced by such women.
The quality needs to be improved by improving health facilities including health
infrastructures and recruiting a well trained personnel for provision of maternal
health care services accordingly.
45
Despite the Tanzania’s government’s commitment to universal provision of free
maternal health services, still women in Bumbuli District Council have to pay for
delivery facilities such as gloves when they are out of stock. Therefore health
measures have to be taken to make sure that delivery services, medicine and facilities
are not out of stock.
5.4.2 Regarding Socio–Demographic Factors on Utilisation of Maternal Health
Care Services
The household socio–economic status and mother’s education were the most
important factors associated with the use of antenatal care and skilled attendance at
delivery, therefore there is need to empower women and promote mother’s education
that would yield greater results in increasing the use of maternal health services.
Empowering women and promoting mother’s education would yield greater results
in increasing the use of maternal health care services. The empowerment of socio-
economic status can be done through multi – sectoral development activities such as
women’s micro-credit, life-skill training and non-formal education. Improving
education among women, especially beyond primary school needs to be strong
encouraged by the Government for women to have a right decision on the place of
delivery.
The government and other stakeholders should build more health centers and
dispensaries nearby households to increase accessibility of getting health services
easily. This will be helpful to women who are living far away from health facilities
to attend antenatal clinic.
Physical access to health facilities due to lack of access to timely and appropriate
transport, and economic considerations, are important barriers for women to deliver
at health facilities in Tanzania. Many women do not perceive a need to seek health
facility delivery and increasingly deliver their subsequent children at home. It is
therefore recommended that government should strive to make sure that transport
infrastructure is improved to areas with health centres and at least an ambulance for
every centre.
46
There are several implications of the findings on strategies to promote skilled
assisted deliveries in Tanzania. Improving physical access by facilitating access to
appropriate and affordable transport during labour, and improving the experiences
and outcomes of mothers seeking health facility delivery may increase its uptake.
This should be augmented by health education interventions that improve the
attitudes and subjective value placed on health facility delivery by pregnant mothers,
lowering its opportunity cost and hence increasing demand. Mechanisms to ensure
services are affordable at point of service delivery will be an important adjuvant to
this strategy.
It is recommended that Government should subsidize maternal health services in
order to make it affordable, acceptable and available to women. Also nurses should
encourage women of reproductive age to utilise maternal health by providing a
welcoming and supportive attitude at all contacts.
5.4.3 Regarding Cultural Beliefs and Practices on Utilisation of Maternal Health
Care Services
The findings of the study show that, the cultural beliefs and practices such as TBA,
confidence and power demonstration, fear of operation bar the women from utilising
the MHCS. For that reason, sensitisation and rising of awareness is highly required to
suppress the beliefs and practices.
The findings from this study point to the relevance of community mobilisation
efforts to identify and address community norms and contextual factors hindering the
use of maternal health care services. Therefore, public health strategies involving
traditional birth attendants will be beneficial particularly in Bumbuli District council
where their services are highly utilised.
Health providers also need to be sensitised more towards the needs of the clients
especially the women to improve interpersonal communication. Thus, health care
providers need to be more concerned and caring to the needs of the people they
serve. They should possess integrity, creativity and sensitivity and be the role model
within health care system and in communities.
47
5.5 Limitations and scope for further study
The study surveyed only three wards of Bumbuli District Council with only 110
women as respondents, something might make the study not very generalizable to
Tanzania. Further study is recommended in more than 3 wards and in other districts
in Tanzania with large sample. The further study is also suggested to be done in
urban areas as this one was done in the rural areas.
This study has encountered some limitations and could not include all variables
which could have significant impacts on utilisation of maternal health care services
in Bumbuli District Council. Furthermore the study involved health centre and
dispensaries in three wards of the council thus did not include all health centers and
dispensaries available in District council. This was due to time limit of undertaking
research and inaccessibility of reaching all health centers and dispensaries in all
wards of Bumbuli District council. Therefore having these limitations further
research should be conducted to include all other health centers and dispensaries and
include other factors that were not included in this study but might have effects on
utilisation of health care service among pregnant mothers.
48
REFERENCES
Abor. P.A and Nkrumah G.A. (2013).The Socio-economic Determinants of Maternal
Health Care Utilization in Ghana, University of Ghana Business School
Legon
Adamu.H.S (2011). Utilization of Maternal Health Care Services in Nigeria: An
Analysis of Regional Differences in the Patterns and Determinants of
Maternal Health Care Use: University of Liverpool.
Addai, I. 2000. Determinants of use of maternal-child health services in rural Ghana.
Journal
Adekanle.O.N (2011),Attendance of Antenatal clinic: a randomised trial.Ghana
Medical Journal paper No 45,132-135
Akinyo, A. R. (2009). Factors influencing mother’s choice of place of delivery in
Soroti District, Uganda (Doctoral dissertation, Makerere University).
Andersen, R. (1968). A behavioral Model of Families’ Use of Health Services.
Research Series No. 25. Chicago, IL: Center for Health Administration
Studies, University of Chicago.
Andersen, R. (1995). Revisiting the Behavioral Model and Access to Medical Care:
Does it matter? Journal of Health and Social Behavior, 36(1), 1-10.
Andersen, R., & Newman, J. F. (2005). Societal and Individual Determinants of
Medical Care; Utilisation in the United States. The Milbank Quarterly, 83(4),
1-28.
Babalola S. O. (2014), Factors associated with use of maternal health services in
Haiti: a multilevel analysis, Pan American Journal of Health;36 (1):1–9.
Baltussen, R., & Niessen, L. (2006). Priority setting of health interventions: the need
for multi-criteria decision analysis. Cost effectiveness and resource
allocation, 4(1), 14.behaviours and pregnancy outcomes. Journal of
Reproductive and Child Health, paper No 13, 231-254.
49
Bimal Kanti Paul (1993). Maternal mortality New York: Social Science & Medicine
Biosocial Science 32(1):1-15.
Boulvain,M (2008). Home- based versus hospital-based postnatal care; a randomised
trial. International Journal of obstetrics and Gynaecology, paper No 15, 807-
813
Bumbuli District Council Annual Health Report, (2015).Reproductive and child
health attendance.
Carpenter, C. J. (2010). "A meta-analysis of the effectiveness of health belief model
variables in predicting behaviour". Health Communication 25 (8): 661–669.
Chimankar1.D and Sahoo.H (2011), Factors influencing the Utilisation of Maternal
Health Care Services in Uttarakhand: Ethno Med, 5(3): 209-216
Dagne.E (2010), Role of socio-demographic factors on utilisation of maternal health
care services in Ethiopia: Umea University. education on the use of maternity
services in Enugu, Nigeria. J Obstet
Elo I. T. (1992), Utilisation of maternal health-care services in Peru: the role of
women's education Health Transition Review, Vol. 2, No. 1 pp. 49-69
Falkingham.J (2004), Inequality and Changes in Women's Use of Maternal Health-
care Services in Tajikistan Gynaecol; 26:30-34.
Gage, A. J. (2007). Barriers to the utilisation of maternal health care in rural Mali.
Social science & medicine, 65(8), 1666-1682
Glanz, K. Bishop, D. B. (2010). "The role of behavioral science theory in
development and implementation of public health interventions". Annual
review of public health 31: 399–418
Glanz, K. Bishop, D. B. (2010). "The role of behavioral science theory in
development and implementation of public health interventions". Annual
review of public health 31: 399–418.
50
Harrington,K.(2012), Health care, Retrieved June 20,2015 from the World Wide
web;http://www.wellbeing for women.com/pregnancy-topics/antenatal –care/
Ikeako L.C, Onah H.E, Iloabachie G.C (2006) Influence of formal maternal
Jat.T.R, Nawi.N and Sebastian.M.S (2011), Factors affecting the use of maternal
health services in Madhya Pradesh state of India: a multilevel analysis,
International for equity in health.
King, P. A., Duthie, S. J., To, W. K., & Ma, H. K. (1992). Born Before Arrival
Uncovering the Hazards. Australian and New Zealand journal of obstetrics
and gynaecology, 32(1), 6-9.
Kothari, C. (2004). Research Methodology; Methods and technique, second edition.
New Delhi: New Age International Publishers.
Letamo G, Rakgoasi SD. Factors associated with the non–use of maternal health
services in Botswana. J Health Popul Nutr 2003;21:40-47.
Lily, K. G. Bjune E. and J. Øyvind (2013)Why some women fail to give birth at
health facilities: a qualitative study of women’s perceptions of perinatal care
from rural Southern Malawi. Reproductive Health, Vol., 10, No. 9
Lubbock, L. A., & Stephenson, R. B. (2008). Utilization of maternal health care
services in the department of Matagalpa, Nicaragua. Revista Panamericana de
Salud Pública, 24(2), 75-84.
MacArthur C. 2009. Traditional birth attendant training for improving health
Mekonnen, Y., & Mekonnen, A. (2002). Utilisation of maternal health care services
in Ethiopia.
MOH (1990), National Health Policy, Dar es salaam: Ministry of Health Tanzania
MOH (1994) ‘Mwongozo wa Utekelezaji wa Sera ya Wananchi Kuchangia Gharama
za Hudama ya,Afya Nchini’. Ministry of Health Tanzania
51
Mujinja.P.G and Dr. Tausi M. Kida.T.M (2014) Implications of health sector reforms
in Tanzania: policies, indicators and accessibility to health services; Dar es
salaam, The Economic and Social Research Foundation
Mukong.A (2012), Socioeconomic Determinants of Maternal Health Care Utilisation
in Tanzania: A Decomposition Approach, Cape town; University of Cape
Town
Navaneethan. K and Dharmalingam. A (2002), Utilization of maternal health care
services in Southern India, Social Science & Medicine, Volume 55
Olayinka.O.A et.al (2014), Awareness and barriers to utilisation of maternal health
care services among reproductive women in Amassoma community, Bayelsa
State: International of Nursing and Midwifery Vol.6(1) pp 10 – 15.
Orodho, J. (2004). Essentials of education and social sciences Research methods.
Nairobi: Masola publishers
Parkhurst.J.O, et.al (2005), Health systems factors influencing maternal health
services: a four-country comparison Health Policy , Volume 73, Pages 127
138.
Phillippines, Bill, 2013. Maternal health in computer networking, Retrieved June
2012 from the World WideWeb;http//www.Medicaldictionary. the free
dictionary.com/maternal. Site
REPOA (2006). Delivery of Social Services On Mainland TANZANIA: Are People
Satisfied? Afro barometer Briefing Paper N0. 34 April.
Riaz, A., Zaidi, S., & Khowaja, A. R. (2015). Perceived barriers to utilising maternal
and neonatal health services in contracted-out versus government-managed
health facilities in the rural districts of Pakistan. International Journal of
Health policy and Management, 4(5), 279.
Rosenstock, I. (1974). "Historical Origins of the Health Belief Model". Health
Education Behavior 2 (4): 328–335.
52
Shija.A.E, Msovela.J and Mboera.L.E.G (2001). Maternal health in fifty years of
Tanzania independence: Challenges and opportunities of reducing maternal
mortality; Journal of Health Research, Volume 13
Sibley, L., Sipe, T. A., & Koblinsky, M. (2004). Does traditional birth attendant
training improve referral of women with obstetric complications: a review of
the evidence. Social Science & Medicine, 59(8), 1757-1768.
Simkhada. B, Teijlingen.E.R, Porter. M, Simkhada, P (2008), Factors affecting the
utilisation of antenatal care in developing countries: systematic review of the
literature, Journal of Advanced Nursing, Volume 61, Issue 3, pages 244–260,
Tibandebage, P., H. Semboja, P. Mujinja and H. Ngonyani (2001), Private Sector
Development: The Case of Private Health Facilities‘, ESRF Discussion
Paper No.26.
Tsawe, M., Moto, A., Netshivhera, T., Ralesego, L., Nyathi, C., & Susuman, A. S.
(2015). Factors influencing the use of maternal healthcare services and
childhood immunization in Swaziland. International journal for equity in
health, 14(1), 32.
UNICEF (1980) The Situation of Women and Children, London: Oxford University
Press.
URT (2013) Neonatal and Child Health Profile. Available at:
http://www.who.int/maternal_child_ado... . Accessed on Thursday, June 2015
Van Etten, G.M. (1976) Rural Health Development in Tanzania, Van Gorcun, Assen:
visited 11/7/2015.
WHO (2007) World Health Report of 2007, WHO Geneva Amsterdam WHO.
Maternal Mortality. Fact sheet, 2012.
World Health Organization (WHO) 2013. Maternal health in computer networking,
Retrieved August 5 2013 from the World Wide
Web:http//www.who.int/topics/maternal-health/en/site visited 21/7/2015.
53
APPENDICES
Appendix 1 QUESTIONNAIRES (English version)
Background Information of respondents
Age...........................................
Village…………………………..
Tribe……………………………..
Religion………………………….
Circle a correct option from the below questions.
1. Marital status
A. Single
B. Separated
C. Married
D. Widowed
2. Occupation of respondent
A. Peasant
B. Business
C. Employed
D. Self employed
3. How far is the nearest health facility from your home?
A. Less than 1 kilometre
B. 1 – 2 kilometres
C. 3 – 4 kilometres
D. Over 5 kilometres
54
4. What type of health facility found at your area?
A. Public
B. Private
5. Has it got maternity services?
A. Yes
B. No
6. How long would it take you to reach the health facility?
A. Less than 1 hour
B. 1 – 2 hours
C. 3 – 4 hours
D. Over 5 hours
7. Do you attend antenatal clinic?
A. Yes
B. No
8. Did you attend antenatal clinic during your previous pregnancy?
A. Yes
B. No
9. .How many times did you visit the clinic?
A. Once
B. Twice
C. Thrice
D. Four times
E. over 4 times
55
10. Where did you deliver your baby during your previous pregnancy?
A. At home
B. At a Traditional birth attendant (TBA)
C. Public Clinic
D. Private Clinic
11. How far is the nearest health facility from your home?
A. Less than 1 Kilometre
B. 1-2 Kilometres
C. 3- 4 Kilometres]
D. Over 5 kilometres
12. What is your family income per day? In Tsh
A. 1000-2000
B. 2000-5000
C. Above 5000
13. Do you pay for the ante- natal services?
a. Yes
b. No
14. If Yes with above what are the Payment for?
a. Gloves
b. Consultation fee
c. Medicine
d. Staff allowance
56
Appendix 1: Dodoso kwa akina mama
Taarifa kuhusu Historia yako.
Umri...............................
Kijiji...........................................
Kabila.........................................
Dini........................................................
Zungushia jibu ambalo ni sahihi.
1. Hadhi yako ya ndoa kwa sasa.
A. Sijaolewa
B. Mmetengana
C. Nimeolewa
D. Mjane
2. Unafanya shughuli gani?
A. Mkulima
B. Mfanya biashara
C. Nimeajiriwa na Serikali
D. Nimejiajiri mwenyewe.
3. Kwa wastani kuna umbali gani toka nyumbani kwako kwenda kituo cha
Afya?
A. Chini ya kilometa moja
B. Kilometa 1-2
C. Kilometa 3-4
D. Zaidi ya kilometa 5
4. Je Huduma gani ya Afya ambayo ipo karibu?
A. Serikalini
B. Binafsi
57
5. Je ulishawahi kupata huduma ya Uzazi?
A. Ndiyo
B. Hapana
6. Je unatumia muda gani kufika Kituo cha Afya?
A. Chini ya saa 1
B. Masaa 1-2
C. Masaa 3-4
D. Zaidi ya Masaa 5
7. Je uliudhuria kliniki ya Wajawazito?
A. Ndiyo
B. Hapana
8. Je uliudhuria kliniki katika ujauzito uliopita?
A. Ndiyo
B. Hapana
9. Uliudhuria Kliniki mara ngapi?
A. Mara moja
B. Mara mbili
C. Mara tatu
D. Mara Nne
E. Zaidi ya mara nne.
10. Mtoto wako wa mwisho ulijifungulia wapi?
A. Nyumbani
B. Wakunga wa jadi
C. Kliniki ya Serikalini
D. Kliniki Binafsi
58
11. Je kuna umbali gani kutoka nyumbani?
A. Chini ya Kilometa 1
B. Kilometa 1-2
C. Kilometa 3-4
D. Zaidi ya kilometa 5
12. Je Kipato cha Familia kwa siku ni Shilingi ngapi?
A. 1000-2000
B. 2000-5000
C. Zaidi ya 5000
13. Je unalipa huduma ya mama mjamzito
a) Ndiyo
b) Hapana
14. Kama jibu ni ndiyo je gharama zipi unalipia?
a) Mipira ya mikononi
b) Ada ya kumwona daktari
c) Dawa
d) Posho za watumishi