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morbidity and mortality .About 64% of the4,5

Nigerianpregnant population would visit modern healthfacilities at least once before delivery for prenatalcare . The Nigerian rural communities are at thedisadvantaged end of the skewed distribution ofmodern health facilities and personnel, traditionalbirth attendants (TBAs), therefore play crucial roleshere in both prenatal and maternity care .Pregnant women in rural area have adduced manyreasons to explain the less than optimal uptake oforthodox medical services. These include cost, pooraccessibility of facilities, negative staff attitude, lackof medications and medical supplies and poororganization of services . The antenatal careprogramme in Africa is patterned after the westernpol icy that involves mult ip le vis i t andinvestigations. . This places enormous workload onthe health care provider with resultant poororganization, content and service delivery. TheWHO has enunciated a newer focused antenatal carep o l i c y f o r c l i e n t s c l a s s i f i e d a s l o wrisk. .This involve reduced number of visits (fourvisits) and investigations . Tested over 18 months in53 clinics and compared with outcomes in 26 otherclinics that offer the standard care policy, this newmodel was found not to be associated with any

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INTRODUCTIONDeveloping countries especially in sub-SaharanAfrica bear the greatest burden of maternal mortalityg l o b a l l y w i t h N i g e r i a c o n t r i b u t i n gdisproportionately high figures . Almost twodecades after the Nairobi Safe Motherhood Initiative(SMI) conference in 1987, higher figures arereturned from the rural areas of the country .Realizing the millennium development goal (MDG)of reducing maternal mortality by 75% by 2015 mustadopt approaches that embrace all segments of thesociety, rural and urban alike.The African traditional society places invaluablepremium on offspring. Childbirth in not only greetedwith resounding joy in the family and communitybut it also serve to elevate the social standing offamilies. Nigerian women receive pregnancy withjoy and realize the need for medical care to ensuresafe delivery of a healthy infant. They therefore inmost cases seek prenatal care from the orthodox carecenters, the traditional birth attendants, spiritualists,charlatans and herbal practitioners. Antenatal carehas been shown to reduce maternal and perinatal

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Correspondence: Dr OUJ UmeoraEmail:oujair@yahoo.com

Nigerian Journal of Clinical PracticeSept. 2008 Vol 11(3):260-264

IMPLEMENTING THE NEW WHO ANTENATAL CARE MODEL: VOICESFROM END USERS IN A RURAL NIGERIAN COMMUNITY.

*OUJ Umeora , *BN Ejikeme , *I Sunday-Adeoye , **RN Ogu

ABSTRACTContext:

Aim:

Results:

Conclusion

Department of Obstetrics & Gynaecology, **Ebonyi State University Teaching Hospital, Abakaliki, EbonyiState.**University of Port-Harcourt Teaching Hospital,Port-Harcourt, Rivers State.

The recommended WHO antenatal focused visits with reduced number of visits and tests is yet to beimplemented in many communities in rural Nigeria.

This paper evaluated the attitude of antenatal clients in a rural mission hospital to the new antenatalmodel.

One hundred and forty-four clients were interviewed. Prior to discussion, none had heard of the newantenatal care model. More than half of them will prefer the traditional policy with multiple visits to the newmodel. The traditional visit was said to be more reassuring and provides the clients time away from their routinechores/occupations and afford them the opportunity to interact with other expectant mothers and get acquaintedwith the health care providers.

: To realize the goals of the new WHO recommended antenatal model in rural Nigeria, massenlightenment and education must precede its gradual and cautious introduction.

Key Words: antenatal care, clients, rural, WHO. (Accepted 13 July 2007)

Study Design: Focus group discussions were carried out bi-weekly for 12weeeks with consenting bookedantenatal clients. The topic guide was developed following interactions with prenatal clients at a referraltertiary center.

Short Report

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Mission Hospital- all located in the capital town ofAbakaliki, about 40km away) were grouped togetherand numbered. The nurse in charge of the antenatalclinic informed the women that some of them to beselected would hold discussions with the specialistObstetrician & Gynaecologist and were given thechance to opt out of the group. She subsequently wrotedown each number consecutively on a piece of paperto correspond to the number remaining in the group.These pieces of paper were folded and dropped in abasket. Then the women drew from the baskets. Thosewho drew the numbers 1 to 6 were recruited for thediscussion. The discussion took place in a relaxed andcordial environment in the Consultant's clinic that wasspacious to comfortably sit all discussants. The detailsof the study were explained to the discussants whogave verbal consent. The Medical officer acted as thesecretary and jotted down all discussions and views ofall participants. These were developed after eachsession. The principal investigator who is also theconsultant Obstetrician/Gynaecologist had structureda topic guide following in depth interviews with tenprenatal clients at the Ebonyi State UniversityTeaching Hospital Abakaliki the major referralcenter.The investigator introduced the topic and explainedextensively the recommended antenatal model,comparing it with the standard setting and x-rayingthe benefit derivable from the new policy. Theparticipant duly understood the new antenatal model.At the end of the session they were directly asked tostate their preferred mode of antenatal care. Eachsession lasted between 40 and 55 minutes. Nodiscussant attended more than a session. Excludedfrom the study were primigravidae and otherexpectant women who have not accessed the orthodoxantenatal care from modern health facilities andwould therefore not be able to make comparisons withthe new WHO model. Others excluded were clientswith medical disorders or any complications since thenew model is intended for low risk cases. Theantenatal records of the subjects were examined fortheir socio-biological data. Their social class wasderivable from the interactions of the woman'seducational status and her spouse's earning a formulafound useful for theAfrican setting

One hundred and forty-four women were interviewedin 24 sessions during the period. The subjects rangedin age from 17years to 40 years with a mean of 25.3years. Teenagers constituted 13.9% but the majority40.3% were within the 25 to 29 years age bracket(table1).Nulliparas were not included in the study. Thirty-seven (25.7%) of the subjects have had two deliveries.

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RESULTS

Increased risk for both mother and infants. Inaddition, it reduced the time and resources requiredfor antenatal care, limiting the frequency of visits,clinical procedures and follow up actions to thoseproven to be effective in promoting positive maternaland neonatal outcomes .Most centers in Nigeria are yet to implement this newmodel of prenatal care. Ndubia Igbeagu is a ruralagrarian community in Izzi Local government Area(LGA) of Ebonyi State. It has been home to a missionhospital since the 1960s. The orthodox andtraditional modes are the predominant health caresystems accessed by the population. The TBAs, andherbal practitioners provide the traditional care. TheTBAs enjoy a pride of place here with teemingclientele of expectant mothers. Illiteracy and povertyare prevalent in the society. Farming is their majoroccupation with women involved in manualoccupations regarded widely as masculine in theother part of southeast Nigeria. They are mainlyChristian and animists. The males have over bearinginfluence in reproductive health decision-making.The mission hospital is staffed with a ConsultantObstetrician and Gynaecologist as well as medicalofficers, midwives and nurses. It operates thetraditional antenatal clinic routine on Tuesday andFridays when the consultant is on seat. A typicalantenatal care begins with prayers, then health talkslaced with advertisement for medical supplies.Songs, choruses and dances thereafter follow.Subsequently the clients queue for blood pressuremeasurement with urinalysis before consultation andpalpations by the nurses. Clients with complaints,risk factors or medical disorders are referred to thespecialist Obstetrician/Gynaecologist for furtherassessment. An average of sixty-four expectantwomen attend the antenatal clinic weekly, while theannual delivery average is 1,080.This study aims to assess the desirability of the WHOrecommended antenatal care regimen amongantenatal care attendees in a rural Nigeriancommunity.

This was a qualitative survey that employed multiplesessions of focus group discussions with randomlyselected antenatal clinic attendees at the St. Vincent'shospital, Ndubia. It lasted 11 weeks (January 10 toMarch 28 2006). In each of the clinic days, after theprayer and dancing session when the clinic isadjudged 'full', primiparous and multiparousexpectant mothers who accessed prenatal care intheir previous pregnancy(ies) at the index facility orany other orthodox referral center (The TeachingHospital, The Federal Medical Centre or The Mile 4

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MATERIALSAND METHODSStudy Design

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Primiparas and grandmultiparas constituted 14.6%and 13.2% respectively. The average parity was 3. Abulk of the respondents either had no formaleducation at all or had just had some form of primaryeducation 47.2% and 42.4% respectively. Noneattained post secondary education. They weremainly engaged in subsistence farming 47.9% while7.6% of them were casual labourers who undertookjobs in quarries or construction sites for daily wages.They were predominantly Christians 70.1% (table1).Forty-four of the subjects or 30.6% preferred the newantenatal care model, eighty-three or 57.6% wouldrather stick to the standard care, while seventeen(11.8%) were undecided. Table 2 shows thedistribution of the subjects according to theirpreferences with regards to their social classes andpresence or absence of a previous obstetric/perinatalcomplication. There were no clients who belong tothe upper classes 1 and 11. Majority (59.1%) of thosewho would rather continue with the standard modelof care belong to social class V; 40.9% were inclasses 111 or IV. This was in contradistinction of the61.4% of those in classes 111 and IV who prefer thenewer model. Only 38.6% of those in this newergroup belong to class V.Fifteen (65.2%) of the 23 mothers with previousobstetric or perinatal complications preferred thestandard schedule of multiple visits, three wanted thenew approached adopted while one was undecided.For those who would want the new model with fewervisits, the limitations of hospital visit would createmore time for other economic ventures:'

For others it saves time and cost:

An important but worrisome fact emerged fromsome of the respondents:

For the majority who would want to continue withthe traditional regime, many reasons were advancedto defend their preference. Many believed thatmultiple visits not only qualify them to consult withthe medical doctor but also enable practitioners

when we come for hospital check up less frequently,we will have more time to go to our farms or even goto the markets and sell our goods, that will be verygood for us and our families.'

'if we take to this your new system, it means we aregoing to come to the hospital only four times and wewill pay hospital fees only four times, that will saveour money and even time'.

'Coming less frequently to the hospital for 'oyibo'medicine, will give us more time to spend with ourlocal midwives (TBAs) and they will have enoughtime to make our pregnancies normal and babies liewell.'

detect their problems and reassure them of theviability of the pregnancies.

Prenatal visit afford some women time to be awayfrom their routine engagement, get to the hospitalinteract with fellow expectant mothers, dance andloosen up.

Furthermore, coming to the hospital entails economiccommitment in terms of hospital services and supplycharges. Perinatal visits afford the women opportunityto reap some financial benefits from their husband

Some respondents reasoned thus:

For me, the most important thing is the talk (healthtalk) they give us any time you come. They are veryimportant and you need to hear them many times andthey will help you'.

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When you come many 'many' times, the nurse can nowallow you to see the doctor and that is good for thebaby'.'You see, it is difficult to notice all the problems atonce, it is only when you come repeatedly that they(care providers) can detect your problem and treatyou well 'well' (adequately)'.'We need to come every time and let the nurse tell youthat your baby is fine, that makes us happy any time wecome'.

'Doctor, you know that we engage in 'hard' workeveryday, it is only when we come here or visit thelocal midwives (TBAs) that we have time to relax andenjoy, even you meet other pregnant women like youand talk about many things that will help you and thebaby'.'Don't you know we enjoy this dance each time wecome here, in fact I look forward to it. If you ask me tocome only four time that means I will come only fourtimes. No! I enjoy dancing and other women willagree with me. It helps us relax and make the baby inyour 'stomach' (uterus) active and healthy.

'Let me tell you, things are very hard now, my husbanddoes not have money and even when he has, hepretends he does not and will hardly give youanything. It is only when I am going to the hospitalthat he gives me money and often times I will tell himan amount more than I will pay in the hospital and usethe rest in for other things. I want to continue comingto the hospital every time so that I will be collectingmore money from him.'

'The hospital is not where you go always, so you haveto keep going to know the place very well and even getto know the nurses very well. You know nurses are verywicked, you doctors are better and very caring butwhen you know the nurses and she has seen you manytimes, she will not be wicked to you when you come todeliver (in labour).'

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DISCUSSIONThis study highlights the information andcommunication gaps existing between the urban andrural segments of the Nigerian society. Whereas thenew WHO antenatal model has been subject of manyconferences, workshops and seminars in the urbancenters, the population in the hinterlands, home tomajority of the citizens, was yet to hear anything of it.All the participants in the focus group discussionswere ignorant of this modification. Alreadydisadvantaged by the sparse modern healthcareinstitutions and care providers, there is greater need toreach out to the rural populace if the efforts to realizethe MDGs are to be fruitful'It was also evident that the rural women attach moreimportance to prenatal care obtainable from orthodoxor traditional health care settings. They howeveraccord preeminence to the traditional birthinstitutions. They repose implicit confidence on theuntrained TBAs believing they are naturally endowedwith capacities to 'keep or make' pregnancy normaland ensure correct fetal presentation and positioning.Imogie and co-workers in Edo State had earlierelaborated on the place of TBAs in maternity careespecially among the rural population. The TBAs livewithin the community, often with long history offamily practice through generations. They areculturally integrated, providing easy accessible,affordable and culturally acceptable health careservices . Many expectant mothers access antenatalcare in multiples facilities (traditional and modern) .A slight inconsistency in orthodox care delivery mayresult in a major shift towards the TBAs.Varied were the many attractions for orthodoxantenatal care for these mothers but adequateunderstanding of the organization and content ofprenatal services were lacking. Some women enjoyedthe perceived freedom from routine chores andoccupation, the social environment provided andrelaxed atmosphere with dancing and songs. Littleimportance was accorded clinical assessment. Therole of the medical doctor was not understood, assome mothers believed that repeated number of visitsor favouritism rather than clinical condition orpresence of risk factors qualify a client to consult witha doctor. That not withstanding, they savour thereassurances of personal and fetal health after eachclinical evaluation.The higher preference of the standard care withmultiple visits to the new model with limited numberof visits by the Nigerian rural community isinstructive. The WHO trial was undertaken in clinicsin South/Latin America, the Middle East and Far Eastbut none in Africa. A similar project to limit antenatalvisits and improve utilization in Harare. Zimbabwealso elicited no enthusiasm from the population .Since the rural populations of sub SaharanAfrica bearthe greatest burden of maternal mortality, it might beworthwhile for such trials to be carried out in theregion. However, it was noted that though not

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Table 1: Age and Parity Distribution of Subjects.

Table 2:

Table 3:

Educational Status, Occupation andReligiousAffinity of the Subject

Antenatal Care Preferences ofRespondents and Social Class Distribution

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significant, majority of those who would prefer thenew model were higher in social strata than thosewho will not. This might be due to differences intheir educational background, with the moreeducated ones being more amenable tounderstanding the need for changes to enhanceservice delivery and client satisfaction withoutcompromising maternal or fetal outcome. Themajority of those yet undecided were also in thehigher class. They may need more time to processthe information. It can therefore be inferred that withfurther background education, the new model maybecome more acceptable to a greater majority. Theneed for the girl-child education and womenempowerment as foundations for the attainment ofthe MDGs cannot be over emphasized.

Women in the rural Ebonyi State know theimportance of prenatal care and they hold on to theroutines of care that have survived through time. Thenew antenatal care model interpreted within theircultural and traditional context might derail analready established pattern of orthodox care andmay encourage further patronage of the TBAs. Poorfemale education and lack of women empowermentare background factors in the poor desirability forchange in the antenatal clinic schedule. Attempttherefore to implement this recommended model inthe rural areas must be preceded by mass campaigns,education and community mobilization. There mayalso be need for modification in the model to make itmore adaptable to the needs of the rural community,thereby ensuring acceptability and increase intake oforthodox prenatal care services.

. World Health Organization. Reduction ofm a t e r n a l m o r t a l i t y . A j o i n tWHO/UNF/UNICEF/World Bank Statement,1999, Geneva WHO, pp 4-34.

Maternal Mortality in Nigeria:The Real Issues. Afr J Reprod Health 1997; 1(1):7-13.

Clinicalcorrelates and trends in hospital maternalmortality in rural Nigeria. Journ ObstetGynaecol 2006; 9(2):139-140.

How effectiveis antenatal care in preventing maternalmortality and serious morbidity?An overviewof evidence. Paed Perinat epidemiol 2001;15(Suppl. 1):1-42

CONCLUSION

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