Effect of Free Maternal Health Care Program on Health-seeking Behavior of Women during Pregnancy, Intra-partum and Postpartum Periods in Cross River State of Nigeria: A Mixed Method Study

Betta Edu, Thomas U. Agan, Emmanuel Monjok, Krystyna Makoweicka


BACKGROUND: Increasing the percentage of maternal health service utilization in health facilities, through cost-removal policy is important in reducing maternal deaths. The Cross River State Government of Nigeria introduced a cost-removal policy in 2009, under the umbrella of “PROJECT HOPE” where free maternal health services are provided. Since its inception, there has been no formal evaluation of its effectiveness. 

AIM: This study aims to evaluate the effect of the free maternal health care program on the health care-seeking behaviours of pregnant women in Cross River State, Nigeria.

METHOD: A mixed method approach (quantitative and qualitative methods) was used to describe the effect of free maternal health care intervention. The quantitative component uses data on maternal health service utilisation obtained from PROJECT HOPE and Nigeria Demographic Health Survey. The qualitative part uses Focus Group Discussions to examine women's perception of the program.

RESULTS: Results suggest weak evidence of change in maternal health care service utilization, as 95% Confidence Intervals overlap even though point estimate suggest increase in utilization. Results of quantitative data show increase in the percentage of women accessing maternal health services. This increase is greater than the population growth rate of Cross River State which is 2.9%, from 2010 to 2013. This increase is likely to be a genuine increase in maternal health care utilisation. Qualitative results showed that women perceived that there have been increases in the number of women who utilize Antenatal care, delivery and Post Partum Care at health facilities, following the removal of direct cost of maternal health services. There is urban and rural differences as well as between communities closer to health facility and those further off. Perceived barriers to utilization are indirect cost of service utilization, poor information dissemination especially in rural areas, perceived poor quality of care at facilities including drug and consumables stock-outs, geographical barriers, inadequate health work force, and poor attitude of skilled health workers and lack of trust in the health system.

CONCLUSION: Reasons for Maternal health care utilisation even under a cost-removal policy is multi-factorial. Therefore, in addition to fee-removal, the government must be committed to addressing other deterrents so as to significantly increase maternal health care service utilisation.


Free maternal health care service, utilization, Cross River State, Nigeria.

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UNICEF. Basic Indicators. UNICEF, 2013. http://www.unicef.org/sowc2013/files/Table_1_Stat_Tables_SWCR2013_ENGLISH.pdf

Aboagye E, et al. Maternal Health-seeking Behaviour: The role of financing and organisation of health services in Ghana. Global Journal of Health Science. 2013;5(5):67-79. https://doi.org/10.5539/gjhs.v5n5p67 PMid:23985108 PMCid:PMC4776872

Okonofua F, et al. Traditional versus Birth Attendants in provision of maternity care: call for paradigm shift. African journal of Reproductive Health. 2014;18(1):11-15. PMid:24796164

WHO. Indicators to Monitor Maternal Health Goals - Report of a Technical Working Group. Geneva, 1994.

Harvey SA, et al. Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bulletin of the World Health Organisation. 2007;85(10):733-820. https://doi.org/10.2471/blt.06.038455

Graham WJ, et al. "Can skilled attendance at delivery reduce maternal mortality in developing countries" safe motherhood strategies: A review of the evidence. Studies in Health Services Organisation & Policy (SHSOP). 2001;17:97-130.

National Population Commission (NPC) (Nigeria . Nigeria Demographic And Health survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International, 2014.

Babalola S, et al. Determinants of use of maternal health services in Nigeria- looking beyond individual and household factors. BMC Pregnancy and Childbirth. 2009;9(43). https://doi.org/10.1186/1471-2393-9-43

CRSMOH. Cross River State Research and Statistics. Cross River, Nigeria: Ministry of Health Headquarters, Calabar, Nigeria, 2013.

El-Khoury M et al. A Review of Public Expenditure Management in Nigeria: Cross River State Report. Bethesda, MD, USA: Health Systems 20/20 project, 2012.

Tulsi Chanrai Foundation. Primary Health: Cross River state 2013. 2013. http://www.tcfnigeria.org/index.php?option=com_content&view=article&id=126&Itemid=548

Olaniran N et al. Mobilizing the community to utilize obstetric services, Cross River State, Nigeria. International Journal of Gynecology & Obstetrics. 1997;59: S181–S9. https://doi.org/10.1016/S0020-7292(97)00164-1

WHO. The World Health Report-Health System financing: the path to universal coverage, 2010.

Witter S, et al. Providing free maternal health care: Ten lessons from an evaluation of the national delivery excemption policy in Ghana. Global Health Action, 2009. https://doi.org/10.3402/gha.v2i0.1881 PMid:20027275 PMCid:PMC2779941

WHO. Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. Geneva: WHO, 2004.

Nanda P. Gender dimensions of user fees: Implications for women utilization of health care. Reproductive Health Matters. 2002;10(20):127-34. https://doi.org/10.1016/S0968-8080(02)00083-6

Oxfam international. UK in Nepal: supporting maternal health and free health care. united Kingdom: oxfam international, 2013.

Koenig M, et al. Maternal health and care seeking Behavior in Bangladesh: Findings from a national survey. International family planning perspectives. 2007;33(2):75-82. https://doi.org/10.1363/3307507 PMid:17588851

Nahar S, et al. The hidden cost of 'free' maternity care in Dhaka, Bangladesh. Health policy and planning. 1998;13(4):417-22. https://doi.org/10.1093/heapol/13.4.417 PMid:10346033

WHO. Maternal mortality country profiles (Trends in maternal mortality: 1990-2013). Geneva: WHO, 2014.

Good Health at low cost 25 years on. london: London School of Hygiene and tropical Medicine, 2011.

Gilson L. The lessons of user fee experience in Africa. Health Policy and Planning. 1997;12(4):273–85. https://doi.org/10.1093/oxfordjournals.heapol.a018882 PMid:10176263

Haddad S, et al. Quality, cost and utilisation of health services in developing countries: a longitudinal study in Zaire. Social Science and Medicine. 1995;40(6):743-53. https://doi.org/10.1016/0277-9536(94)00134-F

Bennett S, et al. Health Financing: Designing and Implementing Pro-Poor Policies. London: DFID Health Systems Resource Centre, 2001.

Schneider H, et al. The impact of free maternal health care in South Africa. Safe motherhood initiatives: critical issues London: Reproductive health matters. 2000.

Wilkinson D, et al. Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa (Review). Bulletin of the World Health Organization. 2001;79(7):665-71. PMid:11477970 PMCid:PMC2566476

Bourbonnais N. Implementing Free Maternal Health Care in Kenya: Challenges, Strategies, and Recommendations. Kenya National Commission on Human Rights, 2013.

Miller N. Free maternity services in Kenya [Internet]: Maternal Health Task Force, 2013. [cited 2014].

Warren C, et al. Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya. Biomed central pregnancy and childbirth. 2013;13 (21).

FEM Health. Effects of subsidising maternal and neonatal health care in Burkina Faso: "it's good but still not enough"! Burkina Faso, 2014.

De Allegri M, et al. "Determinants of utilisation of maternal care services after the reduction of user fees: A case study from rural Burkina Faso." Health policy and planning. 2011;99(3):210-8. https://doi.org/10.1016/j.healthpol.2010.10.010 PMid:21056505

Belaid L, et al. An Implementation Evaluation of a policy aiming to improve Financial Access to maternal Health care in Djibo District, Burkinafaso. BMC Pregnancy and Childbirth. 2012;12:143. https://doi.org/10.1186/1471-2393-12-143 PMid:23216874 PMCid:PMC3538061

The World Bank. Burundi: Investing in Safer Births. World Bank, 2012.

UNICEF. Government's commitment to maternal and child health care in Burundi. Burundi: UNICEF, 2009.

Blanchet NJ, et al. The effect of Ghana's National Health Insurance Scheme on Health care utilization. Ghana Medical Journal. 2012;46(2):76-84. PMid:22942455 PMCid:PMC3426378

HERA. Evaluation of the free maternal health care initiative in Ghana Accra, Ghana and Reet Belgium, 2013.

Witter S, et al. An exploratory study of the policy process and early implementation of free NHIS coverage for pregnant women in Ghana. Biomed central. 2013;12(16).

Galadanci HS, et al. Programs and Policies for Reducing Maternal Mortality in Kano State, Nigeria: A Review. African Journal of Reproductive Health. 2010;14(3):31-6.

Okonofua F, et al. Advocay for free maternal and child health care in Nigeria- Results and outcome, 2010.

Emmanuel N, et al. Consumer Knowledge and availability of maternal and child health services: a challange for achieving MDG 4 and % in Southeast Nigeria. Biomed central Health Service Research. 2013;13(55). https://doi.org/10.1186/1472-6963-13-53

Creswell JW. Research design: Qualitative, quantitative, and mixed method approaches. 2nd ed. United States of America: SAGE publications Inc, 2003.

Wikipedia contributors. Cross River State. Wikipedia: The Free Encyclopedia, 2014.

National Population Commission. National Demographic Health Survey 2008. maryland USA, 2009.

Mate KS, et al. Challenges for Routine Health System Data Management in a Large Public Programme to Prevent Mother-to-Child HIV Transmission in South Africa. PLoS ONE. 2009;4 (5):e5483. https://doi.org/10.1371/journal.pone.0005483 PMid:19434234 PMCid:PMC2677154

WHO. Antenatal care coverage percentage. Geneva: WHO, 2006.

University of North Carolina; Carolina Population Center. Just this Indicator: percent of women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to the pregnancy. North Carolina USA. 2013. Available from: www.cpc.unc.edu/measure/prh/rh...of...antenatal-care.../generate_doc.

Watts M, et al. More than the sum of the parts: research methods in group interviewing. British Educational Research Journal. 1987;13(25-34). https://doi.org/10.1080/0141192870130103

Bricki N, et al. A Guide to Using Qualitative Research Methodology. MSF, 2007.

Africa Progress Panel. Maternal Health: investing in the Life Line of Healthy Societies & Economies. Africa Progress Panel, 2010.

Archibong EI, et al. Review of Policies and Programs for Reducing Maternal Mortality and Promoting Maternal Health in Cross River State, Nigeria. African Journal of Reproductive Health. 2010;14(3):37.

Okonofua F. Reducing Maternal mortality in Nigeria: An approach through policy research and capacity building. African journal of Reproductive Health. 2010;14(3):9. PMid:21243914

Andersen, R. "Revisiting the behavioral model and access to medical care: does it matter?". Journal of Health Social Behaviour. 1995;36(1):1-10. https://doi.org/10.2307/2137284

WHO. Monitoring the building blocks of health system: a handbook of indicators and their measurement strategies. Geniva: WHO, 2010.

WHO. Working Together For Health; The World Health Report 2006. Geneva, Switzerland: WHO, 2006.

Lincento O, et al. Antenatal Care. Opportunities for Africa's Newborns. Partneship for Maternal, Newborn and Child Health, WHO, Geneva, Switzerland.

DOI: http://dx.doi.org/10.3889/oamjms.2017.075

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