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CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY

The third world countries typically Nigeria sees ante-natal care to be an important tool in

mother’s health and curtailing infirmities that may alter with the health of the mother and the

Baby (Parker, 2018). Also utilization of antenatal care services among pregnant women is highly

encouraging since most women in the third world countries like Nigeria invest quality time to

always go for antenatal clinic so as to ameliorate any diseases condition that can affect the child

(WHO, 2018).

The antenatal period presents an important opportunity for identifying threats to the mother and

unborn baby’s health, as well as for counseling on nutrition, birth preparedness, delivery care

and family planning options after the birth. According to Onamade (2021), the Global

Demographic and Health survey compiler estimated that about 500,000 women die each year

from pregnancy related complications and about 55,000 of these deaths occur in Nigeria.

Nigeria’s population is only 2% of the world’s population, but yet account for over 10% of the

global maternal deaths. In 2015, the World Health Organization (WHO) and the Federal Ministry

of Health in Nigeria reported that 830 women die every day, approximately in Nigeria as a result

of 33 complications at childbirth.

Nigeria was ranked second to India globally in the number of maternal deaths (WHO, 2021).

Thus the ratios of a woman dying from child birth are 1:18 in Nigeria, compared to 1:61 for all

developing countries and 1:29, 800 for Sweden (WHO and FMOH, 2022). Antenatal care (ANC)

offers excellent opportunities for promoting maternal health. This is especially true in developing

countries where access to health care is limited. Given the potential of ANC, it has come under

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sharp focus in recent years. Increasing attention is being given to maximizing its potentials for

providing crucial reproductive health services during pregnancy as part of the continuum of care

for women (Onamade, 2022).

Antenatal care is the clinical assessment of mother and fetus during Pregnancy, for the purpose

of obtaining the best possible outcome for the mother and fetus (Women Health Care 2016). The

health care that a mother receives during pregnancy is important for the survival and well-being

of both the mother and the child. The important areas to maternal health care service such as

antenatal care service; problems in accessing health care and awareness and attitude concerning

maternal health Care Service care Also essential to the survival and well-being of both . The

mother and the child (WHO, 2016)

It is crucial to note that antenatal care is instrumental in the prevention and control of neonatal

infections which include; gonorrhea, malaria, urinary tract infection, bacterial infection.

Antenatal care according to Amentie et al., (2015) is one of the most effective health’s

Interventions for preventing maternal morbidity and mortality particularly in places where the

general health status of the women is poor.

The World Health Organization (1996) estimates that, every minute of every day, somewhere

across the globe and most especially in developing countries, a woman of reproductive age dies

from complications related to pregnancy (Harish and Arindam). But in recent years, it has been

observed that the utilization of antenatal care services has helped in reducing maternal mortality

and morbidity and has received a significant recognition. Implementing and assuring utilization

of effective maternity care for women in the developing world is not an easy task as most

childbearing women are poor and live under harsh condition not suitable for them, while

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adequate care during pregnancy is essential, health care service utilization is extremely low

(Amenti et al., 2018).

For all women of reproductive age, especially for pregnant women, utilization of health care

service is a key determinant of maternal and infant outcomes, including maternal and infant

mortality. The benefits of seeking health care are tremendous particularly in settings and

subgroups where the socioeconomic and public health resources are constrained (Alemayehu,

Haider and Habte, 2017). It is evident that timely antenatal care (ANC) is an opportunity to

prevent the direct causes of maternal mortalities and reduction of fetal and-neonatal deaths

related to obstetric complications. Thus, antenatal care is one of the recommended cares to be

provided for pregnant women (Reynold, Wong and Tucker, 2016).

According to the recent WHO recommendations, ANC should start in the first trimester of

pregnancy or early in the second trimester. If the pregnant woman has no serious health problem

and does not need special attention, only four ANC visits suffices (WHO/UNICEF, 2020).

ANC can improve certain outcomes of pregnancy complications such as eclampia, anemia and

syphilis through early detection, management and timely referral of high risk pregnancies,

though the rate of maternal mortality (Alemayehu, et al., 2010)

Generally, ANC during pregnancy can provide an entry into the health system, and for teenagers

in particular such care may be one of the first comprehensive health assessment deemed

necessary (Reynold et al., 2016). Most importantly, utilization of ANC provides the opportunity

to teach women on how to recognize and respond to the signs of obstetric complications as they

may have little knowledge and experience in reproductive health (Reynolds, et al., 2016). The

other added values obtained from ANC service are provision of tetanus toxiod immunization

which is life saving both for the mother and infant, treatment of malaria, anemia and STIS; and

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an entry point for prevention of mother to child transmission of HIV. Provision of health advices

on birth spacing and use of institutional delivery which would significantly improve both

maternal and fetal outcomes are the other important services obtained in the process

(Alemayehu, et al., 2010).

1.2 STATEMENT OF THE PROBLEM

It is worrisome that despite the importance of antenatal care service, most women do not usually

go for antenatal as a result leading to several clinical problems such as; deformation of babies as

a result of self medication, still birth, neonatal infection and so on. Several number of health

workers remain silent on the need for public enlightenment campaign to pregnant women to

always go for antenatal care so as to ameliorate some clinical diseases that are affecting a

number of pregnant women.

Evidence shows that women at rural communities do not invest time strictly for antenatal care

due to negligence, poor educational background, superstitious beliefs, lack of fund to cater for

the expenses of antenatal drugs and services. Therefore, this problem necessitate this study to be

conducted so as to proffer recommendation and solutions on the need for pregnant women to

always go for antenatal care so as to remedy any disease condition that may affect a child and the

mother.

1.3 SIGNIFICANCE OF THE STUDY

The study will revealed the level and utilization of ANC service by pregnant women in Tul

Pushit district; it will help the health personnel to know how to improve on the Strategies that

encourage greater utilization and service.

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Secondly, it is important to all pregnant women in identifying some clinical disease that can be

prevented. Health workers will find this study useful in educating pregnant women to always go

for antenatal clinics. Researchers will find this study useful for research purposes.

1.4 PURPOSE OF THE STUDY

i. To assess the level of knowledge of pregnant women on ANC service utilization in Tul

Community.

ii. To determine if the distance of health facilities influence the utilization of ANC service

by pregnant women in Tul Community.

iii. To determine the effect of health personnel’s attitude toward utilization of ANC service

by pregnant women in Tul Community.

iv. To identify the socio demographic variables such as age, location, religion educational

level and marital status of pregnant women that influence the utilization of ANC service

in Tul Community.

1.5 RESEARCH QUESTIONS

The following research question was asked to guide the researcher on the course of the:

i. What is the level of utilization of antenatal care services among pregnant women in Tul

community?

ii. What extent of the distance of health facility from the targeted pregnant mothers?

iii. To what extent does the health personnel’s attitude influence the utilization of ANC

service by pregnant women in Tul community?

iv. Does the other demographic variable, such as age, occupation, location, marital status and

religion influence the utilization of ANC Services by pregnant women in Tul community,

Pushit district?

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1.6 SCOPE AND DELIMITATION OF THE STUDY

The scope of this study is the assessment of antenatal care service utilization among pregnant

women. The study will be limited to pregnant women living in Tul Community Pushit district.

1.7. DEFINITION OF TERMS

Anaemia: A condition in which there is a deficiency of red cells or of hemoglobin in the blood,

resulting in pallor and weariness.

ANC: Ante natal care

Anemia: A condition in which there is necessary for health welfare, maintenance and protection

of someone or something.

Assessment: Is the ongoing systematic process of collecting, analyzing, and using information

about divisional, department, and programmatic effectiveness in order to improve student

learning

Awareness: Is the ability to directly know and perceive, to feel, or to be cognizant of event or

knowledge or perception of a situation or facts.

Child Birth: Childbirth, also known as labor and delivery, is the ending of pregnancy where one

or more babies leave the uterus by passing through the vagina or by Caesarean section.

Clinical Assessment: Is the process of assessment a patient in a hospital setting to ascertain the

presence of diseases condition.

Deformities: A deformed part, especially of the body; a malformation.

Disease: A disorder of structure or function in a human, animal, or plant, especially one that

produces specific symptoms or that affects a specific location and is not simply a direct result of

physical injury.

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Foetus: The unborn child from the end of the 8th weeks after conception until birth

Hemorrhaged: Hemorrhage is an abnormal escape of blood from an artery, a vein, an arteriole,

a venule or a capillary network.

MDG: Millennium Development Goal

Mortality: The state of being subject to death especially on a large scale.

Neonatal Infection: Is a medical condition affecting the infant

Palpation: Examine (a part of the body) by touch, especially for medical purposes.

Pregnancy: The period from conception to birth. Pregnancy begins with the fertilization of an

ovum (egg) and its implantation. Rate: Consider to be of a certain quality or standard.

Service: The action of helping or doing work for someone

Superstitious Beliefs: Superstition is any belief or practice that is considered irrational or

casualty, a positive belief in fate or magic or fear of that which is unknown

Supernatural: for example, if it arises from ignorance, a misunderstanding of science or

causality, a positive belief in fate or magic, or fear of that which is

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CHAPTER TWO

REVIEW OF RELEVANT LITERATURE

2.0 INTRODUCTION

This chapter deals with review of related literature of some different authors which include the

following conceptual Framework, theoretical framework and empirical studies (Pregnancy, the

aims of antenatal care, Health education during antenatal care services, Services rendered during

antenatal care, Major disorders in pregnancy and Immunization given during pregnancy).

Empirical studies and Summary on review of related literature

2.1 CONCEPTUAL FRAMEWORK

Longman, (2021) defined antenatal care as an advice, supervision, attention, and medical care

given to a pregnancy women during pregnancy labor and puerperium including family planning

the health worker must be aware of the conflict and fear that can be so disturbing to the expected

mother. A successful health worker is the one with certain qualities or characters which include

showing love to his/her patient care, patience and a person who keeps confidential secret. In

adequate socio economic, cultural factors and poor nutrition affect the health of the women.

The pregnant women should be seen every month starting from the confirmation of pregnancy.

When the pregnancy rich 36 weeks, the woman will visit clinic/hospital weekly until delivery

mean while the woman is free to visit the clinic any time she fills, sick or any time she notices

any abnormalities pregnant women should be encouraged to attend antenatal care early either in

the health centre, private maternity or in the hospital, because good antenatal care will reduce the

risk of maternal mortality and morbidity rate in the country.

At each visit the following should be checked e.g weigh, height, Hb, Blood pressure foetal heart

beat, presentation of the baby including Fundal height (Palpation). Also anemia can be checked

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and any abnormalities should be detected and all the findings will be recorded on the antenatal

card.

Advice will also be given in order to make them understand that there is need for them to eat

balance diet for health, and that of her unborn baby including personnel hygiene. There are

maternal morbidity which occur as a result of under utilization of antenatal care which include

obstructed labor, anemia hemorrhaged, pre-eclampia, eclampia are common causes of maternal

morbidity rate in childhood which is generally preventable Birth related infections are common

problem of women during puerperal period. According to safe mother hood, sepsis infection

arising during birth is a leading cause of maternal death in developing countries. Antenatal care

is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the

best Possible outcome for the, mother and fetus (Women Health Care. 2016).

2.2 THEORETICAL FRAMEWORK

The theoretical framework is conducted using several subtopics that include the following:

2.2.1 Pregnancy

Adams (2016) stated that pregnancy is a condition where by a women is having a developing

embryo of fetus in her body. It starts from conception to the delivery of the fetus. The normal

duration is 280 days (40 weeks or 9 months and 7 days) counted from the first day of the last

normal menstrual period, Pregnancy or conception. According to Myles is a fusion of the sperm

with secondary oocyte (ovum) to form the “Zygote” the process take about 24 hour and normally

occur in the ampulla of the uterine tube (Myle 2016.)

Pregnancy is divided into tree trimesters which include.

i. First trimester

ii. Second trimester

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iii. Third trimester

First Trimester: These trimester start from the day of conception to the three months of

gestation in the trimester, the feotus starts to develop in the uterus. This trimester is a very

delicate process because deformities may occur to some due to hormonal imbalance,

malformation of genes and the effect of some drugs. The first three months is a time where the

organs and other parts of the body are forming the placenta transmits oxygen and nutrients from

maternal blood to the feotus and to excrete them outside

Second Trimester: This trimester starts from the fourth month to the sixth months of gestation.

This trimester is more stable, and there is less risk of miscarriage. There is quickening which is

the first Feotal movement felt by the woman at approximately 18 th to 20th weeks in primigravida

and 16th to 18th weeks in multigravida.

Third Trimester: It starts from seventh months to the ninth months of gestation the feotus need

adequate nourishment for proper growth and development. There is lightening, which is being

experienced in the late state of pregnancy. When the presenting part sinks in to the pelvis and the

cease 10 press on the diaphragm, It occurs shortly before the unset of labor in multigravida and

after 36 weeks in primigravida

2.2.3 The Aims of Ante-natal Care

In the past mothers lost their life due to poor antenatal care there was more maternal mobility

and mortality rate.

The aims of antenatal care service includes

i. To produce a life, mature and healthy baby by a healthy mother at the end of pregnancy

ii. To prepare the mother for toward pleasant child bearing experiences (adequate

preparation for labor successfully)

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iii. To detect early and treat any risk condition that may endangers the life of the women and

her baby.

iv. To have the mother immunized through tetanustaxiod vaccine (TT) so that she pass on to

her baby.

v. To have mother strong enough for lactation to feed and care for the baby and to teach

them how to do this successfully.

2.2.3 Health Education during Ante-Natal Care Service

(Clarke 2021) Health Education is define as advice given to pregnant mothers either individual

or groups in the health facility during ante-natal care services or Health education is usually in

the form of talk given at clinics.

The Health education should be presented in a simple manner that the women will understand

what you are saying and also practical demonstration will make them understand more.

A good balance diet which contains the six classes of food nutrients in adequate amounts and

proportion will support the growth of the feotus.

The food nutrient includes:

i. Protein: Is baby building and energy food e.g Meat, Egg, Fish, Beans, Milk e.t.c

ii. Carbohydrate: Energy giving food e.g Maize, Rice, Yam, Cocoyam, Potatoes, Guinea

Corn e.t.c

iii. Vitamin: Is for protection e.g Orange, Onion, Tomatoes, Water, Melon, Pepper green

Vegetable, Apple and Fish e.t.c

iv. Fats and Oil: Is for production heat e.g Palm oil, Groundnut Oil, Butter, Fish and Fats

v. Minerals: For protection and building of bones e.g salt Potassium, Carrot, Onione.t.c

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vi. Water: Which contain hydrogen and oxygen (H 2O) it constitute the largest part of body

fluid.

Other Topics of Health Education

i. Personal hygiene in pregnancy

ii. Clothing

iii. Exercise and recreation

iv. Care of the breast

v. Family planning

vi. Exclusive Breastfeeding (EBF)

vii. Nutrition in Pregnancy

viii. Marital Relation

ix. Personal cleanliness

2.2.4 Services Rendered During Antenatal Care

First visit

Registration/Booking

Registration: Is the act of accepting a client or pregnant woman in to the health facility there are

two types of cards used in antenatal clinic which include

1. Antenatal care hand card: It is also referred to as number which contain personal data of

the woman e.g name age, address date, occupation and the date of next visit

2. Antenatal care card: The personal data of the woman is recorded in PHC set up the

woman goes with her card while in the hospital the cards are been kept in the hospital in

their visit days the cards are given to them the following information are recorded:

i. History of past and present pregnancy

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ii. Family and social history

The following are also recorded height; weight blood pressure and routine test for pregnant

women are also recorded.

 History taking Jack, (2022) this should take the form of friendly-discussion with the

client, which will later make the client feel comfortable and the health worker will then

gain the client confidence. In obtaining the required information. The health worker

should explain to her why some questions may seem irrelevant to her pregnancy are

asked. The health worker should use the language that the woman understands for good

communication. It is useful to provide privacy, so that the woman may feel confident to

say what she probably consider secret. The health worker should also give her time to

express her feelings and ask questions where possible.

 Menstrual History: The menstrual history must be taken accurately as it is important in

the calculation of the gestation period. The date of the last menstrual period should be

ascertained because the date is the common problem in the antenatal booking clinic. The

first day of the last menstrual period should be obtained as this is used in calculation of

the expected date of delivery (The average duration of pregnancy is calculated from the

first day of the last menstrual period is about 40 weeks. We usually estimate the EDD by

adding 7 days to the day of last menstrual ) period (LMP) and counted back 3 months for

example if the woman’s LMP began on the 2 nd June, the EDD would be 9" march 2020.

Ovulation occurs on the 14 day, and fertilization can only take place thereafter.

2.2.5 Health Education during Antenatal

Ahmed (2016) the health worker must be aware of the condition that can be so disturbing or

problem some to the expected mother health worker must be willing to listen and given

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sympathetic advice, will often help the woman to face any difficulties. The health worker must

be careful, cheerful and sympathetic so that women will know that child bearing is natural event.

What the woman need is the assurance that the physically and psychologically she is secure

under her care

The attitude of the Husband

Myles (2016) the attitude of a caring husband is essential for emotional stability of the pregnant

woman it is expected that the husband should have some understanding of the physical and

emotional demand during pregnancy particularly in regard to nutrition the discomfort of

pregnancy makes some women aggressive at that time, but the husband should exercise patience.

Abdominal Examination

Sally Husband (2016) says that you need to explain to the woman what you are going to do

before starting encourage her to empty her bladder to make palpation easier and prevent

discomfort. Ask her to lie down on her back with the head and shoulder raised on a pillow. Wash

your hands and warm them to avoid reaction to cold hand and the abdominal examination should

be carried out in three stages.

i. Inspection: During inspection the health worker will look for

a. Size, estimate the abdomen in relation to the period of gestation

b. Shape, a primigravida will have strong abdominal muscle while multi-gravida will

have round shape with less firm muscle tone.

c. Scars: This may indicates surgery that might affect the uterus e.g caesarean

section (CS) or fibroid removal

ii. Palpation of the Uterus: During Palpation you will examine the uterus and fundus by

touching try to imagine what you are feeling which includes:

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a. Fundus Height: The fundus of the uterus is palpable using hands. The measurement state

from public bone to the fundus from 20 weeks of gestation the fundus height should

increase by KM per week and tape is used in the measurement. Fundus height is also

measure by using finger that fit between the fundus and landmark (2 finger each for four

weeks) if the fundus is too high in early pregnancy missed the gestation period may be

wrong or there may be more than one fundus or hole

b. Lie: In carryout this, you place your hands on the either side of the abdomen and

gradually move then downward from the fundus, you can feel longitudinal lie which is

between the hands; the fundus is felt across the abdomen in a transverse lie. The lie can

be determine from about 28 weeks but can change frequently because it is still movable

but around 32 weeks it should be longitudinal.

c. Presentation: The part that occupies the lower part of the uterus which includes Cephalic

the head which is the normal one, brown face shoulder and breech presentation use both

hands to find the head, which feels nards and rounded which is removable from side to

side unless fixed on the pelvic inlet. The breach presentation feels more irregular and

does not bend. At 38 weeks most presentation and cephalic

d. Position: Walk your hands across the abdomen the fetal spine curve gently and feels

harder than the front of the body which fell lumpsy because of the limbs. If the position is

left occipital anterior the fetal head is well fixed and when it is right occipital posterior

the feotus head is deflexed. During palpation the ulna border of the left hand is placed on

the fundal area and this is carefully palpated to determine a wether the head or breach

occupied. The fundus hand is placed on either side of the abdomen. In this palpation the

health worker faces the patient. During examination the back of the spine of the foetus is

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identify soft while the limbs felt as irregular shape, the engagement of the fetal head

usually descent into the pelvic brim at the last month in primigravida and during labor in

multigravida.

iii. Auscultation: These involve listening to the fetal heart sound (fits) the fetal heart beat

can be best heard at the back of the feotus using the fetal scope and the heart beat can be

heard at 20 weeks of gestation. It should be twice the rate of the mother heart beat.

2.2.6 Major Disorders of Pregnancy

Mrs. Dashe (2007) said that the most common complication of pregnancy which causes maternal

morbidity and mortality rate includes:

Abortion: Is the interruption of pregnancy before 28 weeks of gestation. The cause of abortion

include both maternal and fetal cause

Maternal Causes of Abortion

i. Hormonal imbalance

ii. Effect of drugs e.g Quinic and mestronge tablet

iii. Infection e.g syphilis, makrya

iv. Incompetence cervix

Fetal Causes of Abortion

i. Early separation of placenta

ii. Abnormalities of gene and chromosomes

Sign and Symptom of abortion

i. Vaginal bleeding

ii. The pulse maybe weak and rapid

iii. Hypertension when there is severe bleeding

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iv. Lower abdominal pain due to uterine contraction

v. There may be deliation of the cervix

Management of Abortion

i. Computer Bedrest

ii. Constant check of vital signs

iii. Personal hygiene

iv. Vaginal examination should be discourage as this will aggregate bleeding

v. Analgetics are given to reduce pain e.g paracetamol and routine drugs of folic acid

fersolate B/complex and multivitamin to prevent anemia.

vi. The abdomen should abstain from sexual intercourse for a while

2.3 ANEMIA IN PREGNANCY

Olmer (2022) stated that anemia is a condition in which the blood haemoglobin (Hb) level is

below normal range for the patient Age % Sex male have higher Hemoglobin than female and

the Hb level of 12gidl and above is normal but about 95% of anemia ceases during pregnancy are

iron deficiency aneamia.

Iron deficiency is the common cause of anemia and is aggravated during pregnancy by the

increase in demand of the feotus.

Sign and symptoms of Anemia in Pregnancy

i. Pale skin, lips and nails

ii. Rapid heart beat

iii. Dizziness

iv. Headache

v. Fatigue

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vi. Oedema

vii. Tachy Cardia

Causes of Anemia

i. Deficiency of iron, folic acid, vitamin B12 vitamin C and protein

ii. Disorder of the bone marrow leukemia

iii. Haemolysis due to congenital abnormality of the red blood cells and other infection

Management of Anemia

i. The woman should eat balance diet rich in protein, vitamin and minerals

ii. In mild cases give oral iron drugs like folic acid, ferrous sulphate, vitamin B e.t.c

Pre – eclampsia

Pre-eclampsia is a potentially dangerous pregnancy complication characterized by high blood

pressure. Pre-eclampsia usually begin after 20 weeks of pregnancy in a woman whose blood

pressure had been normal it can lead to serious even fetal complication of both mother and baby,

also pre-eclampsia with pre-eclampsia you might have high blood pressure, high levels of protein

in urine that indicate kidney damage (proteinuria)

Sign and Symptoms of Pre – eclampsia

i. Excess protein in urine (proteinuria) or other signs of kidney problem

ii. Severe headache

iii. Oedema

iv. Nausea or Vomiting

v. High blood pressure (hypertension) 160/110mmHg and above

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Causes of pre — Eclampsia

The exact cause of pre-eclampsia likely involves several factors. Experts believe it begins in the

placenta – the organ that nourishes the foetus throughout pregnancy early in the pregnancy, new

blood vessels develop and evolve to supply oxygen and nutrients to the placenta. In women with

pre-eclampsia these blood vessels don’t seem to develop or work properly problems with how

well blood circulates in the placenta may lead to the irregular regulation of blood pressure in the

mother.

Management of Pre-eclampsia

i. Vital sign, blood pressure and urine should be closely check and monitor

ii. The woman should be on bed rest and lie on dorsal position with the rest and lie on dorsal

position with the legs elevated with pillow to reduce too much accumulation of fluid in

the lower limb

iii. The woman should be admitted for close supervision and care

Eclampsia

Eclampsia is a rare but serious complication of pre-eclampsia eclampsia is when a person with

pre-eclampsia develops seizure (convulsion) during pregnancy, seizure are episodes of shaking,

confusion and disorientation caused by abdominal brain activities.

Eclampsia typically occurs after the 20th week of pregnancy, its rare and affects less than 3% of

people with pre-eclampsia, eclampsia can cause complication during pregnancy and requires

emergency medical care.

Signs and symptoms of Eclampsia

i. Severe headache

ii. Difficulty in breathing

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iii. Abdominal pain (especially on the upper right side)

iv. Blurred vision, seeing double or loss of vision

v. High blood pressure of about 160/10mmHg and above

Causes of Eclampsia

Eclampsia typically develops from pre-eclampsia high blood pressure (from pre-eclampsia) puts

pressure on your blood vessels, there can be swelling in your brain, which may lead to seizure

genetics and diet can increase your risk for eclampsia.

Complications of Eclampsia

i. Placental Abruption

ii. Still Birth

iii. Preterm Labour

iv. Death

Management of Eclampsia

i. Remove anything that will cause injury to the patient

ii. Clear the air ways and provide oxygen

iii. Constant check of the vitall sign including fetal heat beat

iv. Infusion of 5% destrone 500mls laxis and diazepam injection continue checking the

blood pressure.

Ante –Partum Hemorrhage

Ante- partum hemorrhage (APH) is usually defined as bleeding from the canal after 24 th week of

pregnancy or ante-partum hemorrhage is a bleeding from the genital tract which occurs before 28

weeks of gestation and before the birth of the baby.

It can occur at any time until the second stage of labor is complete

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Signs and Symptoms of Ante-Partum Hemorrhage

i. Bleeding, which may be accompanied by pain (suggestive of abruption) or be painless

(suggesting preevia)

ii. Uterine contraction maybe provoked

iii. There may be associated signs of fetal distress

iv. Dilatation of the cervix with abdominal pain

v. There may be shock as a result hypertension

Causes of Ante-Partum Hemorrhage

i. Placenta Praevia

ii. Placenta abruption

iii. Local causes e.g vulval or cervical infection trauma or tumorn

iv. Partner violence

Complication of Ante-Partum Hemorrhage

i. Premature Labor

ii. Anemia

iii. Infection

iv. Prolonged Hospital stay

Management of Ante-Partum Hemorrhage

i. The patient is keep warm with bed rest

ii. Iv destrose saline is given

iii. Analgesic and iron drugs are given

iv. Hemoglobin should be check

v. Regular checking of vital signs

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Postpartum Hemorrhage

Post Partum Hemorrhage is severe bleeding after giving birth. It’s a serious and dangerous

condition. It’s a serious and a dangerous condition PPH usually occur within 24 hour of child

birth but it can happen up to 12 weeks postpartum when the bleeding is caught early and treated

quickly. It leads to more successful outcome

Sign and Symptom of PPH

i. Increased heart rate

ii. Dizziness

iii. Decreased red blood cell count

iv. Pale or clammy skin

v. Worsening abdominal or pelvic pain

Type of Postpartum Hemorrhage

i. Early postpartum hemorrhage occur within 24 hours of delivery

ii. Late postpartum hemorrhage: This type occurs 24 hours to 6 weeks after delivery

Management of PPH

i. Hospitalization is important whether bleeding is slight or severe any woman who bleed

after 28 weeks of gestation must go to the hospital

ii. Vaginal examination should be avoided as many induce profuse hemorrhage which

maybe uncontrollable

iii. Uterine massage to help the muscle of your uterus to contact

iv. Medication to stimulate contraction

v. Removing retained placental tissue from your uterus

vi. Repairing vaginal, cervical and uterine tear or lacerations

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vii. Blood transfusion

2.4 EMPIRICAL STUDIES

A study conducted by Sesedzai (2022) conducted a study on knowledge and utilization of

antenatal care (ANC) services by pregnant women at a clinic in Ekurhuleni. A quantitative,

Descriptive co relational study was carried out on 90 eligible pregnant women. Data were

collected with a self-administered questionnaire and analyzed with the help of a statistician using

the Epi Info version 7 computer programs. The results of the study indicate that most women

initiated ANC later than the recommendations by the World Health Organization (WHO). Over

half of the respondents had overall good knowledge of ANC, but lacked knowledge of

medication and screening tests done during pregnancy, some danger signs during pregnancy and

of exclusive breastfeeding. Factors that were identified as associated with late initiation of ANC

were current employment status, number of children, transport costs to clinic and number of

antenatal visits.

Sumera, Aftab and Savera (2018) conducted a study on factors affecting the utilization of

antenatal care among pregnant women, a literature review. Antenatal care is the care given to

pregnant women in order to have a safe pregnancy and a healthy baby. Antenatal care is an

important determinant of high maternal mortality rate and one of the basic components of

maternal care on which the life of mothers and babies depend. Thus, Antenatal care is a key

strategy to improve maternal and infant health. Different studies have found that inappropriate

antenatal care has been associated with adverse pregnancy outcomes.

Recently the technical working group of World Health Organization has recommended a

minimum level of care to be eight visits throughout the pregnancy to reduce the maternal

morbidity and mortality. Several studies conducted in different countries on demographic and

23
socio-cultural factors influencing use of maternal health care services, have shown that factors

like maternal age, number of living Children, education, place of residence, occupation, religion

and ethnicity are significantly associated with use of antenatal care The findings of various

factors associated with utilization natal care have not en pure review to been Synthesize

collectively, Therefore, there was a need to carry out a literature review to synthesize findings

Collectively regarding the factors affecting the affecting antenatal care utilization of ante-natal

care.

Hence the objective of this literature review was to appraise the factors affecting the utilization

among pregnant women the findings of this literature review could help in planning and

development strategies for utilization of ante-natal care (ANC) among Pregnant women.

2.5 SUMMARY OF LITERATURE REVIEW

This chapter with review of related literature of some different authors which Include the

following conceptional Framework, theoretical framework (Pregnancy, the aim of antenatal care,

health education during antenatal care services, Services rendered during antenatal Care, Major

disorder in Pregnancy and Immunization given during pregnancy.

Empirical studies and Summary on review of related literature Antenatal care as an advice,

supervision, attention, and medical care given to pregnancy women during pregnancy labor and

puerperium including family planning the health worker must be aware of the conflict and fear

that can be so disturbing to the expected mother. A successful health worker is the one with

certain qualities or characters which include showing love to his/her patient care, knowledgeable,

patience and a person who keeps confidential secret. Inadequate socio – economic, cultural

factors and poor nutrition affecting the health of the woman

24
CHAPTER THREE

RESEARCH METHODOLOGY

3.1 INTRODUCTION

This chapter discusses the research methodology under the following; research design, study

area, population of the study, sample and sampling techniques, instrument for data collection,

method of data collection and method of data analysis.

3.2 RESEARCH DESIGN

The research design that was employed in this study was survey that was used in ascertaining the

objective of the study. Hence this design was chosen to gain access to population of the study as

generalizable.

3.3 STUDY AREA

The area of study is Tul Community in Pushit District, Mangu Local Government Area of

Plateau State. The major tribe in Tul is predominantly the Mwaghavul people and other tribes

like the Ngas, Igbo, Mupun and others Tul is located at the south east of Mangu Local

Government along Pankshin road in central part of Plateau State.

Tul community of Pushit district is blessed with facilities such as health facilities, nursery,

primary and secondary schools with tertiary institution respectively. Medically the inhabitant

benefit from primary health care (PHC) and clinic establish by Government and private

individual and are mostly located in the nearby village around the area of study. The inhabitants

of Tul community of Pushit district are 85% farmers there are few business persons and other

civil servants like Teachers, medical personnel and politicians.

25
The major crops produce in Tul community are Maize, Irish Potatoes, Groundnut, vegetables

such as tomatoes pepper and others. With many other basic infrastructures like road leading in

and out of the study area

3.4 SAMPLE SIZE AND SAMPLING TECHNIQUES

The sampling techniques that was employed in this study was simple random sampling

techniques was drawn from cluster community with the total population of 450 women of child

bearing age gotten from Health facility Register that is, Antenatal care register and postnatal

register respectively. 100 were selected as sample size for the study.

3.5 INSTRUMENT FOR DATA COLLECTION

A self developed questionnaire containing questions in two parts namely: Section A and B.

hence A will contain personal data of the respondents and B will contain questions based on the

objectives of the study the questionnaire will structured based on multiple opt one to ascertain

the objectives of the study.

3.6 METHOD OF DATA COFLECTION

The questionnaire will be administered personally to the respondents by the researcher, the

questionnaire was read out to the respondents who are not literate (by the researcher) so that they

can make their choice from the options provided and thereafter, the questionnaire will be

personally collected from respondents by the researcher.

3.7 METHOD OF DATA ANALYSIS

This study will utilize simple percentages for analysis and presented all data and variables in

frequency distribution tables. Hence this method of suitable for this study because it is easier to

comprehend

In analyzing the data the study the following formula

26
X= Y/100 x 100/1

Where

X = unknown

Y = number of responses

N = sample population size

27
CHAPTER FOUR

DATA PRESENTATION AND ANALYSIS

4.1 INTRODUCTION

This chapter deals with data presentation and analysis of results. A total number of 100

questionnaires were administered to respondents at random. All the questionnaires were and used

for analysis using simple percentages and presented in frequency distribution. Tables as seen

below:

4.2 DATA PRESENTATION SECTION

AGE FREQUENCY PERCENTAGE

≤ 20 Years 20 20%

21 – 30 Years 40 40%

31 – 40 Years 25 25%

41 – 50 Years 15 15%

TOTAL 100 100%

From the above table values, 20 (%) respondents of the women were below are 20 years, 40 (%)

respondents were between 21-30 years, 25 (%) of them were between 31-40 years, 15 (%)

respondents were between 41-50 years and the remaining 25 (%) respondents were above 51

years, therefore the highest respondents in this category are those between age 21-30 years

(40%)

Table 2: Occupation Distribution

OCCUPATION FREQUENCY PERCENTAGE

Civil/Public 25 25%

28
Full Time House Wives 50 50%

Traders 25 25%

TOTAL 100 100%

From table 2 above, 25 (%) respondents of the women identified their occupation as civil

services, 65 (%) respondents of them were full time house wives and the remaining 8 (%)

respondents of them were traders, therefore the highest respondents are the full House Wives

with 50%

Table 3: Educational Qualification

QUALIFICATION FREQUENCY PERCENTAGE

No education 10 10%

Primary Level 20 20%

Secondary Level 40 40%

Tertiary Level 30 30%

TOTAL 100 100%

From qualification of Women Within the community 8 (%) respondents had no formal

education, 20 (%) respondents of them attended Primary Level of Education, 40 (%) respondents

attended Secondary Level of Education and the remaining 30 (%) respondents attended Tertiary

Level of Education, which shows that those in secondary level have the highest responses (40%)

followed tertiary with (30%)

29
Table 4: Religion Distribution

RELIGION FREQUENCY PERCENTAGE

Christian 60 60%

Islam 40 40%

Traditional 0.0 0%

From the table above shows that 60 (%) of the respondents were Christians, 40 (%) are Islamic

worshipers no respondent were Traditional worshipers with 0.0% therefore this shows that the

highest respondents are Christians with 60 (%)

Table 5: Source of Ante-Natal Care Service

SOURCE OF ANC FREQUENCY PERCENTAGE

Primary Health workers 39 39%

Trained Traditional Birth Attendants 1 1%

Untrained Traditional Birth Attendants 0 0%

Community Health Workers 60 60%

TOTAL 100 100%

The table above on the study on source of antenatal care services presented 39 (%) respondents

were of the assertion that health workers are the Primary source of ANC but 1 (%) respondent of

them identified trained by Traditional birth attendant and none identified untrained Traditional

birth attendants. A total number of 60 (%) respondents of the majority shows that community

health workers are the primary source of ANC in the hospital.

30
Table 6: Ante-natal care Services visited when pregnant

OPTION FREQUENCY PERCENTAGE

YES 98 98%

NO 2 2%

TOTAL 100 100%

From table 6: Above shows the value of 98 (%) of the respondents were of the assertion that they

usually visit the ante-natal care services when they were pregnant, while 2 (%) respondents did

not visit ante-natal care when pregnant, this clearly shows that most women visit ante-natal care

clinic when pregnant.

Table 7: Time Attended at first visit

OPTION FREQUENCY PERCENTAGE

1st Trimester 33 33%

2nd 47 47%

TOTAL 100 100%

From table 7 above shows 33 (%) respondents attended first ANC Visit at first trimester, 47 (%)

respondents attended 2nd trimester while 20 (%) respondents attended 3 rd trimester. This clearly

shows that most of the women in the community attended ANC at 2nd trimester.

Table 8: Facility attended at first visit?

OPTION FREQUENCY PERCENTAGE

Hospital 33 33%

Maternity in Your community 66 66%

31
Traditional Birth Attendant 1 1%

House 0 0%

None 0 0%

TOTAL 100 100%

From the table value showed 33 (%) respondents attended their first ANC Visit in hospital, 66

(%) respondents attended their first ANC Visit in maternity in their community, 1 (%)

respondents attended their ANC in Traditional birth attendant. And none attended in house. This

indicated that most of the women attended ANC in maternity and hospital in community.

Table 9: Complications that may arise during Pregnancy

OPTION FREQUENCY PERCENTAGE

YES 10 10%

NO 90 90%

TOTAL 100 100%

Table 9 value showed that 10 (%) admitted that they were aware of the complication that may

arise during pregnancy, while 90 (%) of the respondents do not know the complications that may

arise during Ante-natal. This implies that most women with 90% do not know about the

complications that may arise during pregnancy.

32
Table 10: Access to the Health facilities

OPTION FREQUENCY PERCENTAGE

YES 98 98%

NO 2 2%

TOTAL 100 100%

Table 10 above shows 98 (%) respondents said they have access to health facilities and the

remaining 2 (%) respondents said they do not have access to health facilities. This implies that

majority of the respondents within the research area have access to health care facilities.

Table 11: Distance from the House to the nearest Health Care Center?

OPTION FREQUENCY PERCENTAGE

1KM 60 60%

2KM 15 15%

3KM – 4KM 20 20%

5KM and above 5 5%

TOTAL 100 100%

Table 11 shows that 60 (%) respondents asserted that the distance between them and their health

facility is 1 km. 15 (%) respondents identified 3 km to 4 km and the remaining 5 (%) identified

5km and above. This indicates that most of the respondents live close to health care facility

Table 12: Means of Morbidity to ante-natal facilities

OPTION FREQUENCY PERCENTAGE

Foot 60 60%

33
Care 15 15%

Motorcycle 20 20%

Tricycle 5 5%

Donkey 0 0%

Total 100 100%

From the table above shows 60 (%) respondents of women usually attended ante – natal clinic in

the facilities by foot. 15 (%) respondents go for ANC in the facility using car, 20 (%)

respondents go for ANC in the facilities by motorcycle and 5 (%) respondents go for ANC

facility using Donkey.. This clearly shows that most of the women go for ANC service using

foot.

Table 13: Time spent during Ante-natal visit

OPTION FREQUENCY PERCENTAGE

I spend much time 40 40%

I am being attended to quickly 35 35%

I am not always being 25 25%

attended to quickly

TOTAL 100 100%

From table 13 above shows 40 (%) respondents of the women complaint that they usually spend

much time before they were attended to during ante-natal visit, 35 (%) respondents of women

said they were being attended to quickly, 25 (%) respondents complaint they were not always

34
attended to promptly. This implies that most of the women were not treated well during ante –

natal visit

Table 14: Do they have sufficient Health women in the Health centers?

OPTION FREQUENCY PERCENTAGE

YES 10 10%

NO 90 90%

TOTAL 100 100%

From table 14 above shows 10 (%) respondents of women said there were sufficient health

worker in the health centre. While 90 (%) respondents’ women lamented that there were no

sufficient health worker in the health care facility, this clearly shows that there is shortage of

manpower in the PHC and hospitals

Table 15: The Attitude of Health Personnel in the Health Care Centre

OPTION FREQUENCY PERCENTAGE

Very Positive 50 50%

Poor 20 20%

Manageable 30 30%

TOTAL 100 100%

From the above table 15, 50 (%) respondents shows that attitude of health personnel’s in the

health care centers was very positive, 20 (%) shows that attitude of health personnel’s in the

health care centre’s is poor, while 30 (%) respondents said that the attitude of health personnel in

35
the health centre is manageable. This clearly shows that most of the health personnel in the

health care facilities have positive attitude

4.3 DISCUSSION OF THE FINDINGS

This study revealed that there was a significant relationship between distance to health facilities

and the utilization of antenatal care service among pregnant women in Tul Community in Pushit

District, Mangu Local Government Area of Plateau State. The finding was consistent with that of

Falkingham (2003) in India, whose finding also revealed that utilization of antenatal care service

is directly influenced by distance, Other similar studies whose results supported this finding is

that of Bashour et al, (2008) and NPC (2009) who respective studies found that distance from

health facility directly affected the attendance of women for ANC services. The findings of

Amentie et al., (2015) which strongly supported the findings of this study noted that women who

live in less than 60 minute walk from the health facility was 6.73 times more likely use ANC

compare with lived in far distance from the health facility.

Although several findings in other studies supported that of this study, the result of Ewa et al.,

(2012) indicates there was an insignificant negative association between distance and utilization

of ANC and delivery services. A finding in this study also revealed that the attitude of Health

Personnel in the health facilities significantly influenced the utilization of ANC services by

pregnant women in Tul Community in Pushit District, Mangu Local Government Area of Plateau

State. This finding agreed with a study by Moore et al. (2007) who noted that factors responsible

for non utilization of health facility for delivery among others includes unfriendly attitude of

staff of the health facility, unavailability of staff at health facility, lack of emergency unit in the

health facility and previous uneventful delivery at the health facility. It was also found that

although the attitudes of health personnel did significantly influence the utilization of ANC, the

36
extent to which health personnel’s attitude influence the utilization of ANC wall small. As

majority of the women utilized ANC. And this is supported by Chukwuma et al (2015) who in

his study showed that the level of utilization of orthodox health care facilities for antenatal care

services was comparable to what obtained in many countries in Sub-Sahara Africa.

It is also found that the Educational background of pregnant women in Tul community of Pushit

district Mangu Local Government of Plateau State significantly influenced the utilization of

ANC services.

In agreement with the findings of this study was that of Nagdeve, & Bharati (2003) who noted

that women who had some form of education also had a tendency to a greater awareness of the

existence of maternal healthcare services and understand the benefits in utilizing them. Amentie

et al (2015), in his study also had a similar result where it was found that women who were O

level holders and those with higher educational degrees, utilized ante-natal care more than those

who were not educated or just primary school level. They also found out that the educated

women were more knowledgeable on ante-natal care services than the uneducated women.

It was also found that the level of utilization of ante-natal care services by pregnant women in

Tul community of Pushit District of Mangu Local Government of Plateau State is very high and

that socio-demographic variable did not influence the utilization of ANC on level of usage of

ante-natal care services respondents. The findings of this study is similar to that of Adewoye et

al., (2013) which revealed that majority of the respondents in his study utilized the services and

also had a good knowledge of what it was all about. Although Chukwuma et al., (2015) found

that location, religion, socio – economic status had influence on the utilization of ante-natal care

service; his findings is contrary to that of this study in which all these demographic variable did

not influence the utilization of ante-natal care services

37
CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATION

5.1 SUMMARY

This study investigated assessing the utilization of antenatal care services among pregnant

women in Tul community of Pushit District of Mangu Local Government of Plateau State. To

achieve the objectives, four (4) research questions were drawn. Important Literatures were

sourced and discussed using important headings according to the aim of the study. The

methodology used in conducting this study was primary method that employed the used of

questionnaire in generating data, the sample size of 100 pregnant women were sampled from

Primary Health Care hospital within Tul community. The research design used in conducting this

study was cross sectional survey. The sampling techniques used in this study were simple

random sampling techniques. The method of data collection was through face-to-face contact

with the respondents and administration of questionnaire to elicit useful information. The

statistical tool used in analysis was simple percentages and data was presented in frequency

distribution tables. The results of the study was presented and use for conclusion and

recommendations.

5.2 CONCLUSION

The source of information about antenatal clinic in Mangu Local Government area is from

community health workers and others working the Primary health care centers Tul community.

The appropriate time for attending clinics or hospitals for antenatal is when a woman is when a

women is pregnant but most of the women usually wait till 2 nd trimester followed by fever in 1st

trimester in hospitals across Mangu Local Government Area. It is proving that most of the

women were not aware of the complications that usually arise during pregnancy that will warrant

38
for attending antenatal care to ensure the safety of the pregnancy. It is important to note that

during antenatal care a woman will be weight, test and assess to ensure they do always go down

with any diseases that may alter with the development of the baby. To ensure such do not happen

Women were given prophylactic drugs to prevent against any diseases. The attitude of health

Personnel in the health care centers is very positive and fewer of them have bad attitude towards

Women attending antenatal care, that was way some pregnant women complaint that they spent

much time waiting before they were attended to as a result they usually quarrel with the health

Workers in the hospital during antenatal care.

5.3 RECOMMENDATIONS

From the findings of the research works; the researcher has the following recommendations.

i. Health workers should educate ignorant women on the importance of antenatal health

care services in all the primary health Centers

ii. Antenatal care should be made affordable and cheap even to the common man or free to

every woman in the community.

iii. The government should build more maternity centers and Hospitals so that those who

could not utilize the service because of the distance will have opportunity to do so.

iv. Government should employ more staff man-power (health workers) in the Primary

Health Care centers.

v. Government should make provision for antenatal drugs and equipments adequately

promptly go ensure continuity of antenatal care in Mangu Local Government.

vi. Advocators/health practitioners should organize talks, seminars and workshops for

women to update their knowledge on the need for antenatal health care services.

vii. Provide free education to all girls child and free adult education

39
viii. Pregnant women in Tul community of Tul Community, Pushit District should be

encouraged to start ante-natal care (ANC) in the first Trimester

5.4 SUGGESTION FOR FURTHER STUDY

The study could be duplicated to the whole district of Pushit to enable generalization of findings

on a large scale. A study could investigate the reasons why some women visit private health

facilities before attending antenatal care at public facility.

An in-depth study could be done on limitations, timing, knowledge and utilization of antenatal

care by pregnant

40
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43
QUESTIONNAIRE APPENDIX I

Mwaghavul College of Health,

Technology Pushit.

P.M.B. 300,

Department of Community
Health.

25th/05/2024.

Dear Respondent,

I am a student of the above mentioned institution, currently conducting study on “The Assesment

of the Utilization of Antenatal care Service among Pregnant Women in Tul Community of

Pushit District Mangu Local Government Area, Plateau State”.

The purpose of this questionnaire is to collect data on the study of the above mention topic.

Please do supply the best information as you-can. Your objective responses to the questionnaire

will contribute greatly to knowledge and will be utilize for the purpose intended. Please kindly

respond to the questionnaire, all information provided will be treated as highly confidential.

Yours faithfully,

Ogbele Elizabeth Zachariah

(Researcher).

44
SECTION A

1. Age: 15 – 25 Yrs [ ] 26 – 35 yrs [ ] 36 – 45 [ ] 46 – above [ ].

2. Occupation: Civil/Public Servant [ ] Full House Wife [ ] Trader [ ]

3. Highest Educational Level: None [ ] Primary level [ ]. Secondary level [ ] Tertiary

level

4. Marital Status: Married [ ] Single [ ] Divorce [ ] Widow [ ] Others [ ]

5. Religion: Christian [ ] , Muslim [ ] ATR [ ]. Wealth Index: Low [ ], Middle [ ],

High [ ].

SECTION B:

1. "Source of ANC: Health workers [_ ], Trained traditional birth Attendants [ ], Untrained

Traditional birth Attendants [ ], Community Health workers and others [ ], No one [ ].

2. Did you visit the antenatal care service when pregnant? Yes [ ] No [ ].

3. At what level of the pregnancy did you attend your first ANC: 1 st Trimester [ ], 2nd

Trimester [ ], 3rd Trimester [ ], none [ ].

4. Where did you attend your first ANC Hospital [ ], Maternity in your community [ ],

Traditional birth attendant house [ ], none [ ]

5. How many times did you attend ANC [ ]

6. Where did you deliver: Hospital [ ], Maternity in your community [ ], Traditional birth

attendant house [ ], Home [ ].

7. Are you aware of any complication that may arise during pregnancy? Yes [ ], No [ ].

8. If yes, what complication? Severe headache [ ], Blurred vision [ ], Reduced fetal

movement [ ], Overnight [ ]

9. Do you have access to the health facilities? Yes [ ], No [ ].

45
10. What is the distance from your house to the nearest health care centre? 1 km[ ], 2km

[ ], 3km [ ], 4km [ ], 5km [ ], more than5km [ ].

11. Is there road to the health facility? Yes [ ], No [ ].

12. Means of mobility to antenatal facilities: Foot [ ], Car [ ], Motorcycle [ ], Tricycle [ ],

Donkey [ ], Care and motorcycle [ ].

13. Do you make any preparation for birth? Yes [ ], No [ ]

14. If yes, what form of preparation do you make? Provisions for clean clothes [ ], prepared

for clean instruments for delivery [ ], preparation for transport if needed to a health

facility [ ], other preparations (specify)

15. Do you prefer home delivery or the hospital? Home delivery [ ], Hospital delivery [ ].

16. If home delivery, why? It is comfortable [ ] It is not necessary to go elsewhere [ ] For

privacy reason [ ], Against the local custom [ ], It’s safer [ ], No permission from

husband [ ], Cost less [ ], Attitude of health workers in health centers [ ].

17. What are the conditions of the health care centre’s and their personnel’s? Very neat [ ],

Dirty [ ], Fairly neat [ ], Others (specify)

18. What is the attitude of the health personnel’s in the health care centers? Very positive [ ]

Poor [ ], Manageable [ ].

19. Were you attended to quickly or you spend much time during antenatal visits? I spend

much time [ ], I am being attended to quickly [ ], I am not always attended to quickly [

20. Do they have sufficient health workers in the health center? Yes [ ] No [ ].

46

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