ABSTRACT.
The importance of skilled birth attendants in the reduction of maternal and newborn morbidity
and mortality worldwide cannot be over-emphasized. The midwives service scheme was
established by the National Primary Health Care Development Agency (NPHCDA) in
collaboration with the Nursing and Midwifery Council of Nigeria in 2009 to achieve reduction in
maternal, newborn and under-five mortality in Nigeria, especially in rural communities. The
purpose of the study was to determine how mothers and midwives in selected Area Councils in
Abuja perceive the midwives service scheme. Five objectives and three null hypotheses were
raised to guide the study. Quantitative descriptive survey design was used to study the midwives’
perception while both quantitative and qualitative methods were adopted for the study of
mothers’ perception. The whole MSS midwives (32) in the studied Area Councils were used for
the study while a sample size of 381 mothers was drawn from the population of 1483. Two sets
of researcher-developed questionnaires were used to generate data from the midwives and
mothers; while eight focus group discussion sessions with 83 mothers were also used as a backup
instrument for generating data from the mothers. The instruments were certified valid and
reliable, r = 0.85 and 0.89 using split half reliability test for midwives’ and mother’s
questionnaire respectively. Data were administered directly to respondents by the researcher and
four assistants. Objectives of the study were analysed descriptively, while one-way ANOVA and
paired t-test were used to test the hypotheses at 0.05 level of significance using the Statistical
Package for Social Sciences (SPSS). Data from the focus group discussion were analyzed
thematically and findings from thematic analysis wereused to back up the findings from
statistical analysis. Result showed that midwives and mothers perceived the MSS positively but
factors like poor salary, lack of materials like drugs, electricity and poor attitude of health
workers counted negatively against the scheme. More midwives should be recruited and the
midwives’ salaries enhanced to motivate them.
1
CHAPTER ONE
INTRODUCTION
Background to the study
Pregnancy and childbirth are normal physiological processes that bring joyful experiences to
individuals and families. However, in many parts of the world, pregnancy constitutes a perilous
journey, a risky and potentially fatal experience for millions of women especially in developing
countries. Over 289,000 women die annually from complications during pregnancy, childbirth,
or postpartum period (World Fact book, 2014 andWHO,UNICEF,UNFPA &The World Bank
2014). About 70% of these deaths are largely treatable or at least preventable (UNICEF, 2010)
and nearly all these deaths (over 90%) occur in developingcountries where fertility rates are
higher and a woman’s life time risk of dying during pregnancy and childbirth is over 400 times
higher than in developed countries (Audu, Takai, &Bukar, 2010).
The situation in Nigeria is especially grave as maternal mortality rateas high as630 per 100,000
live births is still recorded (World Health Organization, UNICEF & The World Bank, 2014), thus
including Nigeria among the nations with the highest number of maternal deaths (WHO, 2010,
National Primary Healthcare Development Agency (NPHCDA) 2009). Nigeria makes up only
1% of the total world population but accounts for about 10% of the global estimate for maternal
mortality (FMOH & NPHCDA, 2010). The new-born and under-five mortality rates follow the
same trend with an estimated infant mortality rate of 74/1,000 (Index Mundi, 2014).This ugly
trend has been traced to deliveries being attended to by unskilled birth attendants (N&MCN
Newsletter 2011 & NPHCDA, 2009).
It is against this backdrop that the Midwives Service Scheme [MSS] was initiated in 2003 by the
Nursing and Midwifery Council of Nigeria (N&MCN) though originally as a mandatory service
2
for newly qualified basic midwives (NMCN Newsletter, 2011). Subsequently, the NPHCDA in
collaboration with the Nursing and Midwifery Council of Nigeria (N&MCN) and the FMOH in
2009 expanded the programme to include retired but active midwives, unemployed midwives and
fresh graduates of basic midwifery as a rescue initiative to provide an emergency stopgap to the
human resource shortage of skilled birth attendants at the level of primary health care (PHC)
(Nigerian Health Watch, 2011 and N&MCN Newsletter, 2011).
The choice of MSS as a remedy for maternal, new-born and under-five mortality was informed
by the successes recorded by Egypt through the same means. Egypt witnessed a dramatic
reduction in maternal mortality ratio from 174 per 100,000 live births in 1990s to 84 per 100,000
live births in 2000 and further reduction to 68 per 100,000 in 2003 (UNICEF, 2010). In Sierra
Leone, the high mortality rates in under-fives of 296 per 1000 live births for boys and 269 per
1000 live births for girls in 2004 was attributed to lack of skilled birth attendants among other
factors (Oluwale,2004). In like manner, the outrageous rates of maternal mortality of 2000 per
100,000 live births in Sierra Leone has also been attributed to the lack of skilled birth attendants.
Consequently, the United Nations have chosen to use the percentage of deliveries assisted by
skilled birth attendants as the most important measure of progress towards reducing maternal
mortality because of the high correlation between access to skilled care and better maternal
outcome.
The establishment of MSS is a bold and commendable stance on the part of Nigeria. The MSS
has been locally and internationally perceived as a worthwhile intervention programme. For
instance, the former executive director of NPHCDA Mohammed Ali Pate perceived the scheme
as an important measure towards achieving better maternal and new born health and
strengthening the primary health care system in Nigeria (NPHCDA, 2009). On the global
platform, the MSS has also received positive perception consequent upon which it was nominated
3
for 2012 international award by the Commonwealth Association for Public Health
Administration and Management (CAPAM). (N&MCN 2012). However, the success depends on
how the midwives and mothers – (the key players in the scheme) perceive the scheme. There is
therefore need to ascertain their views with respect to their new role of being solely in charge and
responsible for maternal and child health in the MSS facilities contrary to the conventional
hospital setting. Their perception regarding this scheme will significantly reflect the success or
failure of the scheme since they are key players in the scheme. In the light of the above, there is a
need to find out how they perceive the scheme.
Statement of problem
Deliveries by skilled birth attendants (SBAs) serve as indicators of progress toward reducing
maternal mortality worldwide – (MDG 5). Based on this, midwives were posted to primary health
care facilities in Nigeria under the midwives service scheme to ensure that pregnant women are
attended to by skilled health care providers. The various communities were duly informed of the
presence of the skilled health care providers at the PHC facilities and the need for them to access
care from them. The expectation is that the mothers will comply by using the services of the
midwives.
However, evidence at the health care facilities show poor patronage of the services of these
skilled healthcare providers - MSS midwives.For instance, the total deliveries in Gwako PHC
facility inGwagwalada Area Council in 2012 was 54 and that of Kuchibuyi in Bwari Area
Council was 23, (i.e, the monthly average of approximately 5 and 2 respectively).In addition to
the above, Nigerian Health Watch (2011) reported that mothers still patronize the traditional birth
attendants (TBAs) even with the presence of the midwives in their midst. The implication is that
the women are not getting the care they need and therefore maternal mortality will continue to
4
increase. Having once been part of the MSS, the researcher also observed that some of the
midwives that were posted to the primary health care facilities were not always there when they
were expected to be. The researcher wondered how these key players in MSS (providers and
consumers) perceive the scheme and therefore was motivated to undertake the study.
Purpose of Study
The purpose of the study was to find out how mothers and midwives in selected Area Councils in
Abuja perceive the midwives service scheme. Based on this purpose, the following specific
objectives were set:
Specific Objectives
The specific objectives to the study are to:
1. Assess midwives’ perception of the implementation of the MSS
2. Determine the midwives’ view of their role in the MSS.
3. Ascertain the midwives perception of their remuneration in the MSS.
4. Ascertain the mothers’ perception of the services of the midwives in the MSS.
5. Determine if there is an association between the mothers’ demographics and their
perceived reasons for the MSS.
6. To determine the factors perceived by midwives as negatively influencing provision of
services MSS.
5
Research Hypotheses
The following null hypotheses to be tested at 0.05 level of significance were established to guide
the study.
H01 The mothers’ parity will not significantlyinfluence their perception of the MSS.
H02 There will be no significant difference in the midwives’ qualification and their perception
of theMSS.
H03 There will be no significant difference in the midwives’ years of service in the MSS and
their perception of the scheme.
Significance of Study
It is expected that findings of the study will help to ascertain the perception of mothers and
midwives about MSS. Since the midwives are the principal actors in the scheme and the mothers
are the users of the services provided, the opinion of these two groups of people will go a long
way in buttressing the strengths and weaknesses of the programme (in terms of its formation and
operation) and factors enhancing and/or militating against its efficacy. These findings therefore
will serve as useful guide for policy makers in decisions toward improving or making progressive
changes or adjustments in the programme if necessary. The findings from the study will also add
to the existing body of knowledge as well as serve as a useful reference for other researchers who
will be carrying out studies in related areas. These findings will also be of importance to the
Federal Government of Nigeria in achieving the Millennium Development Goals 4&5. Other
Non-Governmental Organizations or agencies that have interest in women’s health will also
make use of these findings.
6
Scope of Study
This study was delimited to only midwives recruited into MSS who are working in MSS PHC
facilities in Bwari and Gwagwalada Area Councils as well as mothers of child bearing age
pregnant at the time of the study and/or those who have had at least one previous pregnancy and
childbirth since the inception of the scheme in the communities where the midwives are working.
The study was also delimited to eliciting midwives view on the implementation of the MSS, their
role in the scheme and the remuneration of midwives in the scheme. It was also delimited to
eliciting mothers’ views of the services provided by the midwives and if there is an association
between the mothers’ demographics and their perceived reasons for MSS.
Operational definition of terms
Perception of the midwives service scheme: the midwives’ opinion about the implementation of
the scheme, their role in the scheme, and the remuneration of midwives in the scheme.
Perception of role in the midwives service scheme: what the midwives view as their
functions in the PHC facility and whether the stipulated work in MSS is appropriate or too
much for them.
Perception of remuneration in midwives service scheme: this is the view of the midwives about
their salaries in MSS.
Perception of mothers for midwives service scheme: this implies the view of the mothers
regarding the ability of midwives in taking care of mothers during pregnancy and child
birth.