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Government Health Policies, Maternal Educational Status and the State of Maternal/Child Health in Urban Nigeria: Assessment from the NDHS 1999-2008
David B. Ugal
Department of Social Studies, Federal College of Education,
Obudu, Cross River State, Nigeria
daveugal@yahoo.com


ABSTRACT

Despite government policies on reproductive health, maternal and child mortality in Nigeria remains high. This study was undertaken to examine the state of maternal and child health in urban Nigeria. Data used for the study was drawn from the last three National Demographic Health Survey (NDHS). Objectives include antenatal attendance, children vaccination, and educational status. There was little improvement in the educational status of women, all other variables showed, very marginal or no improvement. The majority of the women had antenatal care by Traditional Birth Attendant's (TBAs). Almost 40 percent of the women delivered outside any health facility and about the same figure were assisted by unskilled professionals. Vaccination against childhood killer diseases showed no improvement within the period preceding the latest survey. Up to 2008, only 37.5 percent of children received all vaccinations.

Keywords: Health policies, Maternal Education, Maternal and Child health, Nigeria


BACKGROUND OF THE STUDY

Each year, millions of women, newborns and children worldwide die from preventable causes. While interventions that could save their lives are widely known, they are often not assessable to those most in need (Sines, et al, 2006, & Knippenberg, et al 2005). More than 60 million women deliver at home without skilled care. WHO (2005) maintained that around 530,000 women die from pregnancy related complications with 68,000 of these deaths resulting from unsafe abortion. Furthermore, the World Health Organization (2005) reported that about 4 million babies die within the first month of life (the new born period and more than 3 million die as stillbirths and over 10 million children under the age of 5 also die). Black et al (2003) stated that nearly 99 percent of maternal, newborn and child deaths occur in low and middle income countries.

Nigeria Urban Reproductive Health Initiative NURHI (2009) maintained that Nigeria is Sub-Saharan Africa's most populous nation with 149 million citizens, nearly half of whom are under the age of 15. Despite being an oil rich country, Nigeria has some of the worst health indicators in the world, as evidenced by its health system performance ranking 187 among 191 member states (NURHI, 2009).

Unlike many Sub-Saharan African countries, Nigeria has a highly urbanised population. In 2003 it was estimated that about 47% of Nigerians lived in an urban environment. At present, Nigeria has at least ten cities with over a million residents. Lagos's population is estimated at well over 9 million and the United Nations (UN) projects that by 2015 it will be included in the world's list of “megacities” with over 10 million people. The challenges on Nigeria's urban health infrastructure will only increase. By 2035, over half of Nigeria's poor citizens are projected to be living in urban areas. Most will live in slums with little access to basic facilities (NURHI 2009).

Statement of Problem

Despite various National and International initiatives to improve maternal and child health, more than half a million women and children from developing countries still die each year as a result of complications related to pregnancy and child birth (WHO, 2005, NPC, 1999).

Complications of pregnancy and childbirth are the leading causes of death and disability among women of reproductive age in less developed areas. In addition, at least 20 percent of the burden of disease among children below five years is attributable to conditions directly associated with poor maternal health, nutrition, and the quality of obstetric and newborn care, yet, most of these deaths and sufferings are preventable (NPC, 2004).

This situation is still prevalent despite several interventions aimed to improve maternal and child health. The safe motherhood initiative was introduced to suggest strategic interventions to reduce maternal and child morbidity and mortality. The Integrated Maternal, Newborn and Child Health (IMNCH) Strategy introduced in 2007 to fast track high-impact intervention packages that include nutritional supplement, immunisation, insecticide-treated mosquito nets and prevention of mother- child transmission of HIV has not created any change in the morbidity and mortality rates of mothers and their children.

The United Nations (2007), maintained that its' Millennium Development Goals 4 and 5 -to reduce child and maternal mortality by 75 percent and to achieve universal access to reproductive health by 2015 has made the least progress of all MDGs. At global levels, maternal and child mortality decreased by less than 1 percent per year between 1990 and 2005-far below the 5.5 percent annual improvement needed to reach the target. At this rate, MDGs 4 and 5 will not be met in Asia until 2076 and many years later in Africa.

In the face of all these situations, the reproductive health policies of the Nigerian government has been reviewed severally beginning from 1988 to the latest (IMNCH) in 2007, yet, very little is known about the actual effect of these policies on the state of maternal and child health generally and in urban areas of the country particularly.

There are 11,000 maternal deaths for every 100,000 live births in Nigeria. Every year 59,000 Nigerian women die during pregnancy and child birth-the second in the world (after India). The majority of these deaths, as in the rest of the world, are preventable. While the casual factors can be multiple and complex, governments must be aware about the ongoing loss of women and children's lives (Shiffman, 2007). The Nigerian government has repeatedly identified maternal and child mortality and morbidity as a pressing problem and developed laws and policies in response, however, these actions have not translated into significant improvement in maternal and child health throughout the country. This is manifested in the endemic mortality and morbidity that continued to rise as reported by different scholars (Shiffman & Okonofua, 2006, Bankole et al, 2009, UN, 2007). It is against this backdrop that this paper assessed government health policies, women education and their effect and manifestation on the state of women and children's health in the NDHS of 1999, 2003 and 2008.

Maternal Health Policies in Nigeria

Nigeria's first comprehensive health policy was proposed in 1988- National Health Policy and Strategy to Achieve Health for all Nigerians (1988 National Health Policy) (FGN, 2007). It set a target of “health for all citizens by the year 2000” and recognised primary health care as defined in the 1978 Declaration of Alma-Ata as an integral part of the 1988 National Health Policy. It also stated that the minimum level of primary health services must include “maternal and child health care, including family planning.” Considering Nigeria's three-tier system of governance, and noting that the 1979 Constitution placed most health matters on the concurrent list of responsibilities, thereby authorising the three tiers of government to share responsibilities on matters of health, the National Health Policy (1988) provided for a health-care system with three levels of care: primary, secondary, and tertiary. It assigned responsibility for providing primary health care to the local governments, “with the support of State Ministries of Health”; secondary health care to the state governments; and tertiary health care to the federal government.

Under the Revised National Health Policy (2004), which replaced the 1988 National Health Policy, the provision of three levels of care and division of responsibility for these levels among the three tiers of government, remained applicable. The new policy states that the maternal mortality rate in Nigeria is among the highest in the world and further notes that the government spends only USD 8 per capita on health, despite the international community's recommendation of USD 34 per capita.

The Policy specifically delineates national standards for reproductive health and aims to “create an enabling environment for appropriate action and provide the necessary impetus and guidance to local initiatives in all areas of reproductive health.” Its objectives include reducing maternal morbidity, unwanted pregnancies, and perinatal and neonatal morbidity and mortality; reducing gender imbalance in matters of sexual and reproductive health; and promoting research on reproductive health issues. In addition, it lists strategies for achieving these goals, such as “equitable access to quality reproductive health services,” building the reproductive health capacity of providers, “ensuring availability of appropriate materials for effective reproductive health services,” and undertaking necessary research to address “emerging issues in reproductive health.”14 The Health Sector Reform Programme: Strategic Thrusts with a Logical Framework and Plans of Action, 2004-2007 (Health Sector Reform Programme, 2004) was developed to address priority health problems, including maternal mortality. It recognises the deplorable health status of Nigeria's citizens, and notes that the nation's MMR is one of the highest in the world. Moreover, it states that the absence of a clear constitutional mandate for health at the local-government level diminishes the local governments' obligation to provide primary health care and leaves uncertain the functions of the federal and state governments. The programme also acknowledges the absence of dependable information on the government's health expenditures and the failure of the people to scrutinise the budgetary allocations in this regard. It notes that the constitutional gaps have obstructed the ability of the government to fulfil its responsibility to provide health care and calls for the enactment of a national health act that would remedy this loophole. In the meantime, the programme recognises the need to establish primary health-care facilities that are connected to secondary, referral health facilities to ensure access to emergency obstetric care, stating that this would reduce maternal mortality and morbidity. While the 2004 Health Sector Reform Programme identifies many of the problems of the Nigerian health sector and proffers accurate solutions, these problems still persist.

In addition, the Federal Ministry of Health developed the Integrated Maternal, Newborn and Child Health Strategy in 2007 (2007 IMNCH Strategy). The strategy is composed of intervention packages, which address the main contributing factors to maternal, newborn, and child deaths. These packages shift the focus away from fragmented methods of implementing maternal and child health services, to integrated methods. The strategy, which has three stages of implementation-2007-2009, 2010-2012, and 2013-2015-uses primary health care as its main base. Its specific goals include ensuring that 70% of deliveries occur in health facilities by 2015 and that at least 70% of basic emergency obstetric care will be provided at primary health-care clinics and at general hospitals.

The 2007 IMNCH Strategy recognises that poverty constitutes a barrier to accessing health and aims to institute a Basic Health Insurance Scheme that would ensure free service to pregnant women, newborns, and children under the age of five. It envisages specific roles for the executive, legislative, and judicial arms of the three tiers of government in its implementation and enjoins the First Lady of Nigeria to serve as the Goodwill Ambassador for women and children and to ensure the implementation of the strategy in the country.

Finally, the 2004 National Policy on Population for Sustainable Development, which replaced the initial policy of 1988, includes the specific goal of “improvement in the reproductive health of all Nigerians at every stage of life cycle. The policy outlines objectives that facilitate reaching this goal, including “expanding access and coverage and improving the quality of reproductive and sexual health care services, increasing and strengthening comprehensive family planning services and safe motherhood programmes, and addressing the reproductive health needs of adolescents. Implementation strategies at all levels of the national health system include:

  • The comprehensive provision of “reproductive and sexual health services that are of good quality, equitably accessible, affordable and appropriate to the needs of all members of the community.”
  • The delivery of reproductive- and sexual-health services as an integral part of primary health care, and of the health-care delivery system at all levels.
  • A strengthened and improved referral system for reproductive health services.
  • The review of all existing laws and policies in order to ensure the protection of the reproductive and sexual rights of individuals, including the right to make decisions concerning one's reproductive health without coercion, violence, or discrimination.
  • Requiring governments at all levels to ensure “compliance with relevant treaties, policies and laws supporting the attainment of the highest standard of reproductive health services for all citizens.”
  • The development and implementation of a “comprehensive plan for training and retraining of health care providers in integrated and reproductive health service delivery.”
  • Requiring all tiers of government to provide “adequate funding for reproductive health programmes through creation of appropriate budget lines, increased and timely financial contributions, judicious and transparent use of available funds and the implementation of relevant health sector reforms.”

Objectives of the Study

The broad objective of the study is to assess the impact of the different government reproductive health policies on the status of maternal and child health in urban Nigeria.

Specifically, the study assesses:

  1. Maternal health policies in Nigeria

  2. The educational status of women in the three NDHS

  3. Determine whether Antenatal care has improved in the years preceding the latest NDHS.

  4. Identify place of delivery and assess whether these places have improve.

  5. Assess the level and quality of person(s) who assist women during delivery.

  6. Assess the degree of children vaccination in the years preceding the latest survey.

  7. Identify perceived problems with assessing health care.

  8. Relate maternal education with the status of the variables under assessment.


METHODS

The population covered by the 1993- 2008 NDHS is defined as the universe of all women age 15-49 in Nigeria. A sample of households was selected and all women age 15-49 identified in the households were interviewed.

In the current preliminary census frame, the EAs were grouped by states, by LGAs within a state, and by localities within an LGA. The EAs were stratified separately by urban and rural areas. Any locality with less than 20,000 population in each LGA constitutes the rural area in the LGA.

The primary sampling unit (PSU), a cluster, for the NDHS is defined on the basis of EAs from the 2006 EAs census frame. A minimum requirement of 80 households (400 population) for the cluster size was imposed in the design. If the selected EA was small during the listing process, then a supplemental household listing was conducted in the neighbouring EA. The number of clusters in each state was not allocated proportional to their total population (or households) due to the need to obtain estimates for each of the 36 states and FCT-Abuja. Nigeria is a country where the majority of the population resides in rural areas. With the current allocation, the urban areas in some states were over-sampled in order to provide reliable information for the total urban population at the National level.

Based on the level of non-response found in the 2003 Nigeria DHS, to achieve this target, approximately 36,800 households were selected, and all women age 15-49 were be interviewed. A requirement was to reach a minimum of 950 completed interviews per state. In each state, the number of households was distributed proportionately among its urban and rural areas. The selected households were distributed in 888 clusters in Nigeria, 286 clusters in the urban areas, and 602 clusters in the rural areas. Under this final allocation, it was expected that each of the 36 designated states and FCT-Abuja would have a minimum of 950 completed women interviews The 2008 NDHS sample was selected using a stratified two-stage cluster design consisting of 888 clusters, 286 in the urban and 602 in the rural areas. Once the number of households was allocated to each state, the numbers of clusters (calculated based on an average sample take of 41 completed interviews or about 41 selected households) was calculated by dividing the total sample in the state by the sample take. Finally, all women 15-49 years were interviewed in each cluster, and in half of the selected households about 20 men were interviewed. Before the selection in a state, all EAs were stratified by urban and rural areas.

The analysis involved univariate and bivariate analysis.

RESULTS

This section presents data on the educational status of women in the urban and rural areas of Nigeria and the selected variables directly related to maternal and child health.

Table 1: Educational Status of Women

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A comparative assessment of the educational status of women is crucial in determining the outcome of other variables. This is because education is a change agent and a higher educational qualification brings about change in the health seeking behaviour of women. Data on women's education show that there was only marginal improvement in the educational status of women in the period under review. It is instructive that between 1999, which forms the baseline for assessment, women with higher educational qualification rose from an all time low 6.8 percent in 2003 to a little over eleven percent. The women without any form of education did not change markedly, yet there is a drastic reduction of women with secondary educational qualification from 32.0 percent in 1999 to 30.5 percent in 2008. It follows that the marginal improvement cannot make any appreciable impact on the other variables that depend on education for improvement.

Table 2: Selected variables for Maternal and Child Health
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Table 3: Educational Qualification and Utilisation of Maternal and Child Health
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Antenatal care ensures optimal health outcomes for mothers and baby. Antenatal care from a trained provider is important to monitor the pregnancy and reduce morbidity risks for the mother and child during pregnancy and delivery. Data on antenatal care attendance showed that more than 11 percent of women, up till 2008, were not attended to by anyone, while less than half of the women were attended to by a doctor. The percentage of women who were not attended to by a trained health provider in 2008 was 14.6 percent while in 1999, there were only 13.3 percent showing that there was no improvement in urban maternal antenatal care attendance in the period under review. Educational qualification plays a very dominant role in the uptake of antenatal services. Though the uptake of maternal health services is generally poor, it is obvious from the table that those who were better educated took up the health services better. Those with secondary and higher education took up better antenatal services like a doctor and trained nurse far and above the other levels of education. For instance, those with secondary and higher education had over 30 percent of maternal health with doctors while others had less than 20 percent.

Table 4: Educational Qualification and Place of Delivery
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Increasing the percentage of births delivered in health facilities is an important factor in reducing deaths arising from the complications of pregnancy. The expectation is that if a complication arises during delivering, a trained health worker can manage the complications or refer the matter to the next level of care. Data on place of delivery showed that a majority of deliveries in urban areas of Nigeria during the period preceding the survey took place outside a health facility. This trend did not really change from 1999 to 2008. Almost 40 percent of deliveries took place at home in 2008 and this trend had been there from the 1999 survey. Again, the total percentage of deliveries that took place in a health facility remained abysmally low from the 1999 survey to the one in 2008, with 27.7 percent, 28.9 percent, and 29.7 percent respectively. This is an infinitesimal improvement that does not rub off on the status of women and children's health outcome in the country. Controlling for educational qualification, though the place of delivery is generally poor but those with secondary and higher educational levels were delivered by a trained personnel ranging from a doctor to a nurse. These variables also showed significant relation at the .05 alpha level.

Table 5: Educational Qualification and Assistance Received During Delivery
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In addition to the place of birth, assistance during childbirth is an important variable influencing the birth outcome and the health of mother and infant. The skills and performance of the person providing assistance during delivery determine whether complications are managed and hygienic practices are observed. Data on assistance during delivery has not improved despite government policies. In fact, assistance given by Traditional Birth Attendants (TBAs) rose from 11.6 percent in 2003 to 13.1 percent in 2008 while assistance by a doctor is about 20 percent within same period. Generally, assistance in the periods preceding the surveys was predominantly given by non-professionals. Only qualified personnel attended to a marginal number of women. However, the bivariate analysis show that while the place of delivery has not changed markedly, yet those with higher educational qualification had a slightly more advantage over those less education. For instance, the percentage of those who were attended to by a doctor and a nurse is over forty for those with secondary education and higher.

Table 6: Educational Qualification and Vaccination of Children
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The World Health Organisation considers a child to be fully vaccinated if he or she has received a BCG vaccination against tuberculosis, three doses of DPT vaccine and one dose of measles vaccine. These vaccinations should be received during the first year of life. The trend of vaccinations in the period preceding the three surveys show only a marginal improvement for some and a reduction in others. For instance, 75.0 percent of children were given the BCG vaccine in 1999 but only 70.1 percent and 71.4 percent were given in 2003 and 2008 respectively. Besides, only 37.5 percent of children received all vaccination in 2008. This is an indication that a majority of children are being left out in the immunisation programme of the government.

The perceived problems in accessing health care are important in understanding and addressing the barriers women may face in seeking care in general. The 1999 survey did not capture this but it was captured in the 2003 and 2009 survey. Almost half of the women cited at least one problem in accessing health care. The problems indicated include- where to go, getting permission to go, getting money for treatment, distance to the health facility, availability of transport, not wanting to go alone and concern that there may not be a female provider. The most common problem was getting money for treatment followed by distance to health facility and having to take transport. Less than one in five women reported the other three problems. However, the concern for no drugs available was the commonest problem reported to be affecting women's access to health services.

DISCUSSION OF FINDINGS

Health Policies and Maternal Health

The study found that despite lofty health policies formulation there is a serious lack of commitment to implementing these policies as can be seen in the gross under budgeting of the health sector over the years.
The findings of this paper are in line with several observations that have been made by different organisations and scholars on Nigeria's slow movement towards the achievement of the MDGs. This assertion was aptly captured in the midterm assessment of the MDGs in Nigeria. The progress made was reported thus (FRN, 2007).

The emerging trend in child mortality is of great concern at this mid-point of goal achievement period. Infant mortality rate actually rose from 81 per 1000 live births in the year 2000 to 110 per 1000 live births in 2005/2006, which is farther away from the global target of 30 per 1000 live births in 2015. Besides, the target percentage of one year olds fully immunized is expected to be total; so far, the proportion only increased from 32.8 percent in 2000 to 60 percent in 2007. This slow pace has accounted for the increase in avoidable disease such as polio. Polio cases rose from 201 in 2007 to 651 cases in 2008. With this, Nigeria has 86 percent of the total number of polio cases in the world (FRN, 2007).

On maternal health, the midterm assessment maintained that

reduction of maternal mortality represents a major challenge for Nigeria. Mid way to the target date for achieving the MDGs, the maternal mortality rate should be 440 per 100,000 live births. The reality however shows that in the urban areas, there are 531 deaths per 100,000 live births. Approximately, two thirds of Nigerian women deliver outside of health facilities and without medically skilled attendance present (FRN, 2007).

Women Educational Status and Maternal/Child Health

Strikingly, the findings of this study showed that though there are several government policies and programmes that are geared towards improvement in health services generally and maternal and child health particularly. What is on ground shows that these policies are not either implemented properly or not implemented. Several scholars have drawn the attention of government and other agencies to the poor state of health infrastructure in the country, which contributes directly to the observed poor maternal and child health outcomes. These infrastructure range from inadequate skilled manpower in the hospitals and primary health centres, poor motivation system, inadequate funding, poor management of the health sector resources, weak transparency and accountability framework in the sector.

It is as a result of the slow pace at improving maternal and Child health that the MDGs 4 and 5 to reduce child and maternal mortality by 75 percent and to achieve universal access to reproductive health by 2015 has made the least progress of all MDGs. Things therefore need to be done properly to change the ugly trend.

While many proven, cost-effective ways to save the lives of mothers, newborns, and children exist, they are not always available to those who need them most. Historically overlooked by both safe motherhood and child survival policies and programmes, newborns continue to lack access to cost-effective lifesaving interventions. The Bellagio Study Group on Child Survival estimates that universal coverage (99 percent) of 16 proven newborn health interventions could avert up to 72 percent of all newborn deaths (Fotso & Ezeh, 2009). These include interventions such as tetanus toxoid immunization, skilled attendance at birth, access to emergency obstetric care, immediate and exclusive breastfeeding, drying and keeping the newborn warm, and if needed, resuscitation, care of low birth weight infants, and treatment of infection. The series estimates that 63 percent of child mortality would be prevented with 99 percent coverage of effective and available interventions (Gareth et al, 2006). In addition to newborn interventions, safe water and good sanitation; immunizations; management of diarrhoea, pneumonia, and malaria; appropriate feeding practices; and access to care could significantly reduce child mortality.

The World Bank has estimated that 74 percent of maternal deaths could be averted if all women had access to interventions that address complications of pregnancy and childbirth, especially emergency obstetric care (Adam, & Claeson, 2004). The package of interventions that would prevent these deaths includes good nutrition; access to family planning; care during pregnancy, delivery, and the postpartum period; and referral services for complications.

In developing countries, a mother's death in childbirth means that her newborn will almost certainly die and that her older children are more likely to suffer from disease. Moreover, when mothers are malnourished, ill, or receive inadequate care, their newborns face a higher risk of disease and premature death22. Almost one-quarter of newborns in developing countries are born low birth weight, largely due to their mothers' poor health and nutritional status, which results in increased vulnerability to infection and a higher risk of developmental problems. The quality of care that both mother and newborn receive during pregnancy, at delivery, and in the early postnatal period is essential to ensuring women remain healthy and that children get a strong start. Many stillbirths and newborn deaths could be averted if more women were in good health, well-nourished, and received quality care during pregnancy, labour and delivery, and if both mother and newborn received appropriate care in the postpartum period (Tinker, et al, 2005, Tinker, 1997, Martines et al, 2005).

Health policies and programmes in the fields of maternal, newborn, and child health, have generally focused on one issue alone-targeting interventions to only one of these groups and obscuring important linkages. When approached together and incorporated into integrated programmes, these interventions could save millions of lives at a lower cost than separate initiatives. Linking interventions in packages can reduce costs by allowing greater efficiency in training, monitoring and supervision, and use of integrated systems. Finally, The Lancet Neonatal Survival Series emphasized the importance of the concept of a continuum of care while focusing on saving newborn lives.

The newborn is increasingly being recognized as the vital link between mothers and children. This acknowledgment coincides directly with greater recognition of the importance of the continuum of care. The next step is to apply this understanding in policies and programmes. India, for example, has developed a strategy to reach newborns as well as older children and reproductive aged women, through home and facility-based care25. Similarly, the government of Ethiopia is in the process of incorporating the newborn into existing programmes and policies and is working with the Partnership for Maternal, Newborn, and Child Health to improve MNCH services through a continuum of care.

The Nigerian government must be willing to commit adequate resources to meet the needs of the health system. The system must be significantly overhauled to promote proper co-ordination among the three levels of government-federal, state and local to reduce bureaucratic bottlenecks and wastage of resources.

Periodic monitoring of development with regards to maternal health should be conducted every three to five years. Auditing of facilities needs to be institutionalized to assess every case of maternal morbidity and mortality. Active partnership between government and private sector should be encouraged and vigorously pursued to bring about an effective collaboration for better maternal health services in both private and public health sectors.

In recognition of the fact that a large proportion of births take place with Traditional Birth Attendants (TBAs) and the realization that marginal efforts in the past in training them had only marginal success, government should review the training and related facilities to situate TBAs properly in order to improve the quality of care given by them. Since there is a low level of awareness about pregnancy related problems and a poor health seeking behaviour recorded, substantial attention needs to be devoted to behaviour and attitudinal change through communication programming for maternal and neonatal health promotion for morbidity and mortality reduction (Ugabi & Ugal, 2009 & Ugal, 2010).

Conclusion

This study was undertaken to assess the state of maternal and child health in Nigeria using data from the NDHS, in response to the unacceptably high death rate of mothers and their children in Nigeria. The study found that education as a change agent did not markedly change within the period but its marginally upward change did not affect other variables under consideration. Antenatal care and assistance during delivery remained unchanged.
Following from here, the need to vigorously improve and change the attitude of women towards maternal health services is suggested while holding government responsible for the poor health infrastructure in the country.
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REFERENCES

Adam W. & Claeson, M. 2004. The Millennium Development Goals for Health: Rising to the Challenges Washington, DC, World Bank,.
Bankole, A., Sedgh, G. Okonofua, F., Imarhiagbe,C., Hussain, R.& Wulf, D 2009. Barriers to Safe Motherhood in Nigeria; New York; Guttmacher Institute.
Black, R., Morris, S & Bryce, J. 2003. Where and Why are 10 Million Children Dying Every Year? The Lancet 361 No. 9376, 2226-34
FGN 2007. Mid Term Assessment of the Millennium Development Goals in Nigeria: Office of the Special Assistant to the President on MDGs, Abuja.
Fotso, J.C, Ezeh, A. & Essendi 2009; Maternal Health in Resource -poor Settings: How does Women's' Autonomy influence the Utilisation of obstetric Care Services? Reproductive Health; 6(9) 1742-4755
Gareth J. et al. & The Bellagio Child Survival Study Group, 2003.“How Many Child Deaths Can We Prevent This Year?” The Lancet 362, no. 9377: 65-71.
Knippenberg, R. et al. 2005. Systematic Scaling up of Neonatal Care in Countries. The Lancet neonatal Survival Series No. 3.
Martines, J., et al., 2005. Neonatal Survival: A Call to Action. The Lancet Neonatal Survival Series, No. 3
National Population Commission (NPC) (Nigeria) and ORP Macro. 1999. Demographic and Health Survey 1998, Calverton, Maryland: NPC and ORC Macro.
National Population Commission (NPC) (Nigeria) and ORP Macro. 2004. Demographic and Health Survey 2003, Calverton, Maryland: NPC and ORC Macro.
National Population Commission (NPC) (Nigeria) and ORP Macro. 2009. Demographic and Health Survey 2008, Calverton, Maryland: NPC and ORC Macro
Nigeria Urban Reproductive Health Initiative (2009) Global Program on Family Planning and Reproductive Health, The Johns Hopkins University
Shiffman, J. 2007. Generating Political Priority for Maternal Mortality Reduction in 5 Developing Countries; American Journal of Public Health; 97(5) 796-803.
Shiffman, J.& Okonofua, F.E. 2006. The State of Political Priority for Safe Motherhood in Nigeria. BJOG; 114, 127-133.
Sines, E., Tinker, A & Ruben,J. 2006. The Maternal, Newborn-Child Health Continuum of Care; A Collective Effort to Save Lives: Population Reference Bureau.
Tinker, A & Ransom, E. 2002. Healthy Mothers and Healthy Newborns: The Vital Link, Population Reference Bureau and Saving Newborn Lives Initiative.
Tinker, A et al., 2005. “A Continuum of Care to Save Newborn Lives. The Lancet Neonatal Survival Series, No. 3.
Tinker, A. 1997. Safe Motherhood is a Vital Social and Economic Investment (paper delivered at Technical Consultation on Safe Motherhood), Colombo, Sri Lanka.
Ugabi, J.I. & Ugal, D.B. 2009. Access and Utilization of maternal Health Facilities in Cross River State: A Case Study of Obudu and Ogoja Local Government Areas: Technical Report for ETF
Ugal, D.B. 2010. Household Environment and Maternal Health Among Rural Women of Northern Cross River State, Nigeria, University of Ibadan, Unpublished Ph.D Dissertation.
United Nations, 2007. The Millennium Development Goals Report 2007. http://www.un.org/millenniumgoals/pdf/mdg2007.Retrived 2/03/2010
WHO 2005. The World Health Report; Make Every Mother and Child Count; Geneva.