Challenges to Accessing Ante-Natal and Postnatal Care in Internally Displaced Persons (IDPs) Camps in Nigeria
2 College of Medicine, University of Jos, Jos Plateau State, Nigeria
Citation: Ohihoin AG, et al. Challenges to Accessing Ante- Natal and Postnatal Care in Internally Displaced Persons (IDPs) Camps in Nigeria . Ann Med Health Sci Res. 2021;11:1367-1370.
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Introduction: These Internally Displaced Persons (IDPs) face a lot of challenges which include poor infrastructure and limited access to basic health services including reproductive health services. IDPs are also predisposed to sexual abuse as well as gender-based violence which can result in pregnancies. There is, therefore, the need to document challenges in access to maternal care among this marginalized population to influence policy and overcome the challenges. This study looks at the access to ante-natal and post-natal care in IDP camps in Nigeria.
Methods: Study design is a descriptive cross-sectional study, using mixed methods of qualitative (FGD) and quantitative (semi-structured questionnaire) techniques to interview the respondents.
Results: A total of 587 females took part in the study from which 82 of them were found to be pregnant. 20.7% of the pregnant women sought antenatal care. 34.7% claimed they did not have enough money to seek ante-natal care while the remaining 44.6% had other reasons for not accessing ANC. 91 women (11.7%) of the respondents had infants with an age range 1 month-1 year. Only 35.2% of these nursing mothers had a postpartum check-up after delivery. Of the 91 nursing mothers, 49% gave lack of finances as the reason for not seeking post-partum care.
Conclusion: Access to maternal health care is a major challenge among IDPs. This can impact negatively on the target to achieve the SDGs. Policymakers should, therefore, draft policies that will cater for the maternal health needs of internally displaced Individuals
IDPs; Ante-natal care; Post-natal care; Nigeria
The aim of the Sustainable Development Goal 3 is to ensure healthy lives and promote wellbeing at all ages. The targets include: reducing maternal mortality ratio to less than 70 per 100,000 live births by 2030; ending preventable neonatal deaths and reducing neonatal mortality.  To achieve this goal, all mothers including women in IDP camps should have access to quality maternal care. Maternal health is an important indicator of the overall health system quality because pregnant women thrive well in sanitary, safe, well-staffed and equipped facilities. New mothers survive and thrive better in an efficient health system, when compared to faulty health systems. 
Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. It is essential to provide pre-conception, pre-natal and post-natal care to ensure optimum outcomes and reduce maternal morbidity and mortality.  Making motherhood safer is thus an imperative human right,  services regarding safe motherhood should therefore be available to all women.
Women and children constitute over 70% of internally displaced populations.  They have unique health needs and are vulnerable to different health problems such as unsafe abortions, maternal morbidity and mortality.  Internally Displaced Persons (IDP) has been defined by the United Nations Commission on Refugees (UNHCR) as individuals or people who are forced to flee, but either cannot or do not wish to cross an international border.  Globally, over 40 million people were displaced as a result of wars and violence due to religious and ethnic conflicts in 20159. In Nigeria, over 2 million people are internally displaced due to the Boko Haram insurgency.  These IDPs face several challenges which include poor infrastructure, limited access to basic services, sexual abuse as well as gender-based violence.
There is usually disruption in health services in this situation, which results in low or inadequate prevention of common diseases, resulting from poor access to healthcare,  leaving the women at a higher risk of maternal morbidity and mortality. Routine immunisation services that are not only essential for the mothers but also the children are also compromised. This may impact negatively on infant morbidity and mortality thus contradicting the UNICEF adage which says “healthy children grow to become healthy adults that are capable of creating better lives for themselves and their communities”.  The need for ante-natal and post-natal care in challenged areas cannot, therefore, be over-emphasized and there is a need to document the current status of the quality of care to enact policies for improvement.
This study seeks to document the challenges to accessing maternal care among internally displaced persons in Nigeria to influence policy.
The main objective of this study is to document the challenges to accessing antenatal and post-natal care among internally displaced persons in Nigerian IDP camps.
Materials and Methods
Study design and procedure
The study design was cross-sectional, using mixed methods of qualitative Focus Group Discussions (FGD) and quantitative (semi-structured questionnaire) techniques to interview the respondents. The FGDs was among women of child-bearing age while the quantitative method of interview employed a semistructured questionnaire to determine the proportion of pregnant women and availability of/access to ante-natal and post-natal care services in the camps.
The study was carried out in Benue State, Bornu State and Abuja.
Study participants and sampling
Sample size calculation for cross-sectional study (qualitative variables) was done to estimate sample size. The calculation was based on the proportion of internally displaced persons in Nigeria (9.5%) (UNHCR, 2015); 5% precision at 5% type 1 error was used; level of statistical significance was set at less than 0.05. The calculated sample size was 132, since there was sufficient human resource to collect data; the sample size was fulfilled in each of the four 1 DP camps employed for the study. A total of 587 participants were recruited for the study.
As stated earlier, data collection was done with the use of a semi-structured, interviewer-administered questionnaire and focus group discussions among women of childbearing age.
A total of 587 respondents participated in this study. Study sites were enumerated from three states; which are Borno State, Benue State and the Federal Capital Territory. The median age of the respondents was 30 years; with minimum and maximum age of 14 and 100 years respectively.
Among 537 respondents who stated their occupation; close to three quarters were unskilled (70.8%), 91(16.9%) were skilled and 66(12.3%) were semi-skilled.
Also of the 587 participants a majority (77.5%) were married, 80 (10.7%) were widowed, 78(10.4%) were single and the rest of the 11(1.5%) were either divorced or separated.
Above half 314(53.5%) of the respondents practised Islam, 271 (46.2%) were Christians, while African Traditional worshipers were 2(0.3%).
Out of the 587 respondent, 448 were married; among the respondents, one out of every seven was pregnant.
Eighty-two (14.0%) out of the total 586 respondents were pregnant at the time the survey was conducted. Only 17 (20.7%) of the 82 pregnant women sought antenatal care. The health professionals who provided antenatal care, they were seeing for were doctors (10/17), nurses (4/17) and midwives (3/17).
Of the 82 pregnant women, 39 (47.6% of them were pregnant before the disaster occurred. Also, before the disaster the average gestational age was 4.4 months old while the modal and minimum pregnancy age was one month, however, some pregnancies were as far gone as 7-9 months. Thirty (30/39, 76.9%) sought antenatal care before the disaster, while the remaining nine did not seek antenatal care.
Furthermore, the 37 women out of those who were pregnant before the disaster reported the outcome of their pregnancies as still birth (4/37, 10.8%) Alive (23/37, 62.2%) and miscarriage (10/37, 27%) [Table 1].
|Not enough money to pay for visits||25(34.7)|
|No transportation to get to the clinic or doctor’s office||14(19.4)|
|Did not know where to go to receive care||6(8.3)|
|Could not get an appointment when desired||5(6.9)|
|Had too many other things going on||4(5.6)|
|The wait time at the clinic was too long||4(5.6)|
|No clinic in the camp||4(5.6)|
|No one to take care of children or other family members||3(4.2)|
|Did not want antenatal care||3(4.2)|
|Could not take time off from work or school||2(2.8)|
Table 1: Reasons that prevented pregnant women from getting ante-natal care at all or getting ante-natal care early enough. n=72.
Furthermore, one out of four pregnant women 22 (26.83%) claimed they found it more difficult to get antenatal care since the disaster.
Post-Partum Women and Their Infants
Ninety-one women (11.7%) of the respondents had infants who were one year old or younger. The median and modal age of the infants was 2 months; they had a minimum age of one month old and a maximum of one year.
However, only 32/91 (35.2%) women had a postpartum checkup since the delivery of their infants [Table 2].
|S.N||Reasons that kept women from getting postpartum check-up.||Number (Percent)|
|1||Not enough money or to pay for visit||29(49.1)|
|2||Couldn't get an appointment when desired||22(37.2)|
|3||Didn’t know a postpartum check-up was recommended||13(22.0)|
|4||No transportation to get to the clinic or doctor's office||13(22.0)|
|5||Didn’t know where to go to receive care||8(13.6)|
|6||Had too many other things going on||6(10.2)|
|7||The wait time in the clinic was too long||6(10.2)|
|8||No one to take care of children or other family members||5(5.5)|
|9||Couldn't take time off from work or school||4(4.4)|
|10||There is no clinic in the camp||4(4.4)|
Table 2: Listed below are reasons that kept some women from getting a postpartum check-up. n=59.
Forty (44.0%) of the 91 women due for postpartum check-up said that they found it more difficult to get a post-partum checkup done since the disaster and lack of money was the reason given for not getting post-partum check-up.
Close to half of the women 44 (48.4%) had taken their babies to see a doctor for a check-up after delivery while other women did not [Table 3].
|S.N||Reasons that kept women from taking their babies for a check-up with a doctor since after delivery.||Number (Percent)|
|1||Not enough money or to pay for the visit||38(80.9)|
|2||No transportation to get to the clinic or doctor's office||20(42.6)|
|3||No one to take care of children or other family members||8(17.0)|
|4||Couldn't get an appointment when desired||6(12.8)|
|5||Baby was too sick to go for routine care||6(12.8)|
|6||The wait time in the clinic was too long||6(12.8)|
|7||Didn’t know where to go to receive care||5(10.6)|
|8||Had too many other things going on||4(8.5)|
|9||There is no clinic in the camp||4(8.5)|
Table 3: Below presents reasons that kept women from taking their babies to have a check with a doctor after the babies were born. n=47.
Close to half 41 (45.1%) of post-partum women found it more difficult to have a check-up for their babies since the disaster owing to lack of money and far distance from the camp to the clinic.
The feeding methods practiced by mothers were Breastfeeding and water 36 (53.7%), Mixed feeding- Food/Formula/Breast milk 16 (23.9%), Exclusive breastfeeding 14 (20.9%) and Formula only 1(1.5%). n=67
Also, thirteen women (13/67, 19.4%) were giving their children formula at the time the survey was conducted, however, four out of the thirteen women said they had difficulty getting the formula.
Furthermore, due to the disaster, only (2/13, 15.5%) of the women did not have difficulty getting clean water to mix formula or clean bottles for feeding while the remaining women had difficulty getting water to mix formula and to clean bottles.
The study revealed that 14% of the respondents were pregnant as at the time of conducting the survey and of those pregnant, only about 20% had access to antenatal care. This percentage is lower than the 61% who will have at least four ANC visits in non-conflict situations. This is as obtained from reports of the National Demographic Health Survey.  The reason for not receiving ANC was linked to poor finances 54.1%. This reason for poor ANC uptake is not restricted exclusively to the IDPs as Fagbamigbe and co-workers reported that affordability is a key barrier to accessing ANC in Nigeria. 
There is a positive correlation between ANC attendance and good maternal and fetal outcomes and failure to attend ANC will result in poor maternal and perinatal outcome. IDPs are thus at risk of having poorer maternal and perinatal outcome when compared to the general population. These findings have been echoed by other workers who documented poorer maternal and perinatal outcomes with IDPs. 
It is interesting to note that a greater portion (52.4%) of the pregnancy occurred during the period of the displacement. This result shows that displacement does not necessarily inhibit procreation and maybe a driver of procreation as displaced individuals are devoid of their usual routines and thus have more than enough time to pro-create.
The study revealed that 27% of the pregnancies ended as miscarriage, while 10.8% of the pregnancies ended as stillbirth. This stillbirth rate is higher than the rate in the general population, although the miscarriage rate was only slightly higher than the general population of 22%. [9,13,14] This finding strengthens the fact that pregnancy outcomes among IDPs are worse than that of the general population.
Access to post-partum care was limited for the displaced individuals as only 40.5% had access to any form of post-partum care. This was largely due to a lack of finances to transport to the clinic as seen in 80% of such respondents. Infant feeding options were mainly mixed feeding as seen in 77.7% of respondents with infants.
Mixed feeding is the commonest practice in the general population and it is not unusual that this is also the pattern in the IDP population.
The study has shown that maternal health is a major challenge among IDPs. This is due to limited access to antenatal care services as well as poor post-natal care practices. This will eventually lead to poorer maternal and perinatal indices. Policymakers should therefore draft policies that will cater for the maternal health needs of internally displaced Individuals.
Ethical Approval and Consent to Participate
Ethical approval was obtained for the conduct of this study from the Institutional Review Board (IRB) of the Nigerian Institute of Medical Research (NIMR). A written informed consent was obtained from the participants.
The authors report no competing (commercial/academic) interests.
Consent for Publishing
All authors gave their consent for publishing
The research was funded by Nigerian Institute of Medical Research (NIMR).
We acknowledge Aisa Isa for co-ordinating the participants during the field work, and we also acknowledge Mercy Mayowa Ojetunde for her secretariat input.
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