Sociodemographic Characteristics and Pregnancy outcome of Referred and Booked Parturients in a Nigerian Teaching Hospital

2 , 3 babies . These health problems include complications of pregnancy, pre-existing conditions that worsen during pregnancy and effects of unhealthy lifestyles. With a maternal mortality ratio of 630 deaths/100,000 live births, Nigeria still has one of the highest maternal mortality rates in the world .Nigeria was not able to meet the fourth and fifth Millennium development goals (MDG) which included reduction of child mortality by two thirds for children under five and reduction by threequarters the maternal mortality ratio by the year


INTRODUCTION
Antenatal care (ANC) a component of maternal health care can be defined as care of the woman throughout pregnancy in order to ensure safe delivery of a healthy baby without detrimental 1 effects on the mother's health .The goal of the ANC package is to prepare for birth and parenthood as well as prevent, detect, alleviate, or manage health problems during pregnancy that affect mothers and 2 , 3 babies .These health problems include complications of pregnancy, pre-existing conditions that worsen during pregnancy and effects of unhealthy lifestyles.With a maternal mortality ratio of 630 deaths/100,000 live births, Nigeria still has one of the highest maternal mortality rates in the world .Nigeria was not able to meet the fourth and fifth Millennium development goals (MDG) which included reduction of child mortality by two thirds for children under five and reduction by threequarters the maternal mortality ratio by the year 5 2015 .Attendance at antenatal clinics and receipt of professional delivery care have been associated with 6,7 a reduction in maternal deaths .Antenatal care attendance in Nigeria varies from region to region, however average attendance said to be about 60% and this is much lower than that of neighbouring factors .Booked status is associated with better pregnancy outcome, studies have shown higher maternal and perinatal mortality, higher rates of admission into intensive care and higher rates of 13,14 surgical deliveries among unbooked mothers .
Quality of antenatal care services obtained has also been shown to be critical in enabling women receive a d e q u a t e a n d a p p r o p r i a t e c a r e d u r i n g 15 pregnancy .Some studies have shown high rates of antenatal care coverage co-existing with high maternal and neonatal mortality rates and have identified the gap to be as a result of inadequate or The study population were consecutive pregnant women that were admitted either into the emergency ward or the labour ward of the hospital in active labour.A total of 434 patients were recruited, data was collected through the use of an interviewer administered questionnaire which was made up of sections on sociodemographic characteristics, history of present pregnancy and pregnancy outcome.The questionnaires were administered by research assistants.Information was obtained from the patients at presentation, as much as was possible, from the case folders for the booked cases, from patient relatives and also where necessary from the patients after delivery.The study duration was 6months from June to December 2014.The questionnaire was pre-tested before administering it to the study group.Purposive sampling of consecutive parturient that consented and met the inclusion criteria was done.The inclusion criteria were mainly presentation for emergency obstetric care or intervention and labour while women with less than 28 weeks gestational age were excluded.
The study group was divided into two; booked mothers, and referred mothers.Booked patients or mothers were those who had attended antenatal clinic in our institution while a referred patient was a woman who had not received antenatal care in UITH facility but had been brought for obstetric care.
Ethical approval was obtained from UITH Ethical Review Committee for the survey.Patients also gave informed consent.The data collected was entered into and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.The results were presented using frequency tables and percentages and summarized using relevant descriptive statistics such as means.Association between discrete variables was tested using Chi-square.The level of statistical significance was set at P < 0.05.

RESULTS
A total of 434 patients were reviewed during the study period, of this number 153(35.3%)women were referred while 281(64.7%)were booked.The mean age of the booked patients was 29.4 ± 4.6 years while that of the referred patients was 28.3 ± 5.2, overall mean age was 29.0 ± 4.8 years.

DISCUSSION
Regular antenatal care has significant impact on improving pregnancy outcome and this was also revealed in this study inwhich the booked patients had better maternal and foetal outcomes than the referred patients.Booked patients generally had higher sociodemographic factors such as higher income, higher levels of education and higher social class than the referred.
Two thirds (281, 64.7%) of the study population were booked for antenatal care in the teaching hospital while one third (153, 35.3%) were referred there.Some of the referred patients had already registered and were receiving antenatal care in other facilities while some were not receiving any form of antenatal care at all.Nineteen (12.4%) patients had not previously registered for nor received antenatal care at all in any health facility or had received antenatal care with TBA's in religious centres or at their homes.This is comparable to what was obtained in previous studies in which 16.6% and 13,17 17% had not received antenatal care .In the study byIgberase et al in a rural referral centre 22.4% had pregnant women are said not to attend Antenatal 9 Care (ANC) service during pregnancy .Utilization of antenatal care services is known to be affected by the setting whether rural or urban, with a higher antenatal care attendance in the urban setting and probably explains the slightly lower percentage of such women in this study which was in an urban setting.A statistically significant higher percentage of the singles were referred compared with those who were married, this is probably because the financial and psychological support to enable them make right decisions about obtaining adequate maternity care may be lacking.
Referred mothers were generally younger in age though this was not statistically significant, this is also similar to what was obtained in some previous 9,10 studies .Gravidity which shows the number of pregnancies the parturient has ever had including the present pregnancy was also statistically significant.
Generally more multiparous women had booked for antenatal care and received antenatal care in the Teaching Hospital, this included the grand multiparous women that had had more than 4 parous experiences.This could possibly be as a result of experiences from the previous delivery/ies or increasing awareness of dangers associated increasing parity and grand multiparity which is generally associated with higher maternal and perinatal complications.
Referred patients and spouses were found to have lower educational status, less skilled jobs and lower monthly income resulting in a lower socioeconomic status than the booked patients and all these variables were found to be statistically significant.This was in keeping with previous study by maternal morbidity and mortality .The lower the education the more likely it was to believe myths and probably less likely to identify and differentiate between standard and substandard healthcare facilities.Poor economic status may make it difficult to make informed decisions about appropriate use of standard healthcare services which they may perceive as expensive and unaffordable.Providing free or subsidized antenatal care services will certainly have a positive impact on antenatal care use.
Pregnancy outcomes in the referred mothers were significantly poorer than in the booked mothers, higher incidence of caesarean section rates, NICU admissions and greater number of neonatal deaths were observed.There were more maternal deaths among the referred mothers and more complications requiring specialist intervention.This is similar to the most promising intervention for reducing perinatal mortality and morbidity by the WHO but emphasis on this is quite low .It appears that TBA's still play a significant role in maternal care and this appears to be increasing with the worsening global recession and economic issues Moreover there is a need to ensure that health facilities licensed to offer maternity services are staffed with adequately trained personnel.This would also help to prevent and correct delayed referrals and the attendant problems.The specific reasons for not attending antenatal care were not covered by the research tool.Previous studies have suggested poverty and transportation problems .Knowledge of these factors could likely help to tackle and subsequently help to improve utilization of this important service. .The study was carried out in a Teaching Hospital and this could possibly have had an influence on the status of patients that booked in the study centre.Also, some of the referred cases had received some form of antenatal care in other facilities before presentation.In a tertiary facility like the study centre, prompt and specialist care will ultimately give better outcome than other facilities with limited specialist care.These factors constitute limitations to finding in this study.
In this environment routine and adequate antenatal care is significantly related to favourable maternal and foetal outcomes, especially among parturients with good sociodemographic characteristics.General improvement in levels of literacy as well as training of TBA's will also almost certainly improve antenatal care attendance with a subsequent reduction in maternal and perinatal mortality.

AUTHORS DO NOT HAVE ANY CONFLICT OF INTEREST TO DECLARE.
comparative figures were 88.0% for Benin (2006 DHS), 72.8% for Burkina Faso (2007 DHS), 83.4% for Cameroon (2004 DHS), and 91.9% 8 for Ghana (2003 DHS) .Poor utilization of antenatal care probably contributed to the failure to achieve th th 10 the 4 and 5 millennium developmental goals .Low social class, low income and few educational achievements are some sociodemographic factors that have been shown by Kupek et al in the study in England and Wales to be barriers to early initiation of 11 antenatal care .Local studies here in Nigeria have also revealed that the choice of place to receive ANC and for delivery are influenced by sociodemographic 12

Patients who are unemployed and those who did not indicate their monthly income were not included in analysis of income
÷ 2 : Chi square; *: p value < 0.05 (i.e.statistically significant)

Table 3 :
Relationship between Referral Characteristics and Foetal outcome

Table 4 :
Relationship between Referral Characteristics and Maternal outcome