CHAPTER TWO

REVIEW OF LITERATURE

INTRODUCTION

Our focus in this chapter is to critically examine relevant literature that would assist in explaining the research problem and furthermore recognize the efforts of scholars who had previously contributed immensely to similar research. The chapter intends to deepen the understanding of the study and close the perceived gaps.

Precisely, the chapter will be considered in three sub-headings:

• Conceptual Framework
• Theoretical Framework

2.1 CONCEPTUAL FRAMEWORK

Information Communications Technology

According to Anonymous (2014), I.T is defined as a generic term that covers the acquisition, processing, storage and dissemination of information. It is the application of computers and communication technology in the task of information handling, information and information flow from the generation to the utilization levels. Information Technology is defined as hardware and software products, information system operations and management processes, IT controls frameworks, and the human resources and skills required to develop, use and control these products and processes to generate the required information (Greenstein-Prosch, McKee & Quick, 2008). Information technology was defined as computer software and hardware solutions that provide support of management, operations, and strategists in organizations (Choo & Shahryar, 2013). From the above definitions, it can be drawn that Information technology is a wide term on its own with a range of various definitions. But generally, it refers to any type of technology for the purpose of communication. The definitions provide explanations on the use of electronic devices and technology to manipulate information, noting that it is most common amongst firms and not in personal settings. It deals with computing. On a broader scale, Information Communication Technology (ICT), is often used an extended synonym for IT. It is a more extensive term that stresses the role of unified communications and the integration of telecommunications, computers, as well as necessary enterprise software, middleware, storage, and audio-visual systems, which enable users to access, store, transmit and manipulate information. This confirms the interrelatedness of ICT and IT, but stressing that ICT involves a larger scope than IT.

Components Of Information Technology

According to Anonymous (2014), Information technology can be broken into;Hardware: this refers to physical, tangible and touchable components. It is the part that can be touched and seen. They can be further classified into 4 groups, which are:

Input devices:

these are hardware devices used to send data into the computer. Examples are light Output devices: these are hardware devices through which information is sent out of the computer. They include speakers, printers and monitors.

Central Processing Unit (CPU): this is the part of the computer that performs tasks as it comprises of the microprocessor which is the brain of the computer.

Storage devices: these are hardware components that store data. There are two type- Primary (stores information temporarily) and Secondary (stores information permanently). Examples are RAM and ROM respectively.pen, keyboard and mouse

Software:

this refers to intangible components that can only be seen. They include computer programs and codes that control the hardware devices. A computer program is a set of instructions written to perform a specific task. There are three categories of software, they are:

System software; this provides the basic functionality of the computer. It is made up of the Operating system and Support system with Linux and Diagnostic tools as examples respectively.

Application software; this helps the users to perform specific tasks. Examples are Web browsers and Media development software.

Programing software; this is used by software developers to create, debug, maintain and support other programs and software. Examples are JAVA and BASIC.

Data:

this refers to raw fact and figures that are processed into information. They are generally stored in the electronic devices until they are needed. An example is NAME.

Procedures: these are the laid down rules and regulations that govern the way information is processed and exchanged.

Internet/Network: the internet is a global system of interconnected computer networks that use the standard internet protocol suite or other network to link several billion devices worldwide.

People: this refers to the man-power that is involved in the steps of IT activities. They probably determine the success or failure of information systems.

Elements Of i.c.t

Computer Technology

A computer is an electronic device that is capable of storing and processing information in accordance with a set of instructions. Computer technology is defined as the activity of designing and constructing and programming computers.It has caused massive developments in the transmission of information. In these recent times, you either live with computers or are left behind. The usage of computers now brings about accuracy, precision and efficiency of data.

Concept Of Maternal And Child Health

The health of mothers and children reflects the well-being of the society. Unfortunately, insufficient health care, poor nutrition and the general effects of ill-health have adverse effect on the mortality of these groups of people in the community. High maternal mortality rates remain a constant setback worldwide. World Bank (2011), reports that problems during pregnancy and deliveries are the major reasons for deaths among women of reproductive age in poor resource countries. Maternal mortality is defined as a death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related 9 to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (WHO et al, 2012). Maternal mortality is high in the developing world and remains to be the main cause of death of women in the reproductive age group (González et al, 2006). Almost all the estimated half a million of maternal deaths that happened worldwide each year are believed to be in developing countries (González et al, 2006). Unlike men, women are vulnerable to risks related to maternal health (WHO, 2013). The health of a nation is measured by the health of its people. WHO conceptualizes maternal health as the health of women during pregnancy, childbirth or during the postpartum period (WHO, 2010). Furthermore, maternal health combines the health status of women and how health services are adequate to provide the needs of women. Maternal health is concerned with health problems that can occur during pregnancy, childbirth, the immediate postpartum period and lactation (WHO, 2013). Pregnancy complication that poses a challenge for maternal health continues to hold a high risk of deaths. Maternal mortality, female genital cutting, child marriage, HIV /AIDS and cervical cancer are among the major health problems that account for most morbidity and mortality of women (Nour, 2008) in Umar (2016). A recent estimate by the World Health Organization (WHO) indicates that more than half a million maternal deaths occur every year in pregnancy and childbirth complications. These deaths are, as Filippi et al (2006) in Ebeniro (2012) describes is only 'the tip of the iceberg'. This is indicates that for every woman who dies of pregnancy-related complications, there are more others who experience chronic morbidity due to this phenomenon annually. A total of 10-20 million women suffer in physical, sexual and mental illnesses and disabilities (Horton, 2010) in Hanson (2013).

Giving birth can pose many risks to a woman‘s health with their attendant physical, mental and social impacts. If these risks are not effectively managed in a timely manner they can create serious health problems for both mothers and children, and can even result to death (WHO, 2010). Maternal deaths occur predominantly during labour, delivery, or in the immediate postpartum period, often due to anaemia, infections, or hypertensive disorders. Roughly half of maternal deaths take place within one day of childbirth (Hogan, Goreman and Naghavi, 2010). Most of these deaths are preventable (Jowett, 2000) but prevention hinges on women being able to access the right maternal health information and services. Prevention of maternal death is also related to delivery in a health facility ensuring that women are close to emergency services and sufficient skilled care should the need arise (Campbell and Graham, 2006). Despite international efforts to improve maternal health, this remains one of the most threatening health challenges. Pregnancy and birth-related complications are leading causes of death among women of reproductive age in developing countries. In 2008 alone, an estimated 358,000 women worldwide died from complications related to pregnancy or childbirth. The vast majority of maternal deaths occur in developing countries where haemorrhage, obstructed labour, eclampsia, abortion, sepsis and infection are the main causes of pregnancy-related complications (WHO et al, 2010).When adequate health facilities, proper treatment and emergency care are available, these complications should not lead to death. However, too often these essential maternal health care resources are not available or accessible to women in need. The fifth millennium development goal (MDGs 5) - to reduce maternal mortality by three-quarter between 1990 and 2015 is one of the prime objectives of countries struggling with poor quality of health care for women. 11 There have been instances of leadership on maternal health in the northern part of Nigeria. Kano was the first state in Nigeria to introduce free maternal care in 2003, but the care has not always been sustained. Currently, terror attacks by the extremist group Boko Haram have forced many health and development policy implementation personnel to shut down or scale back operations in the North, and public health experts are afraid that prolonged insecurity might destroy the gains and efforts made in the last decade.

Significance Of Maternal And Child Health Information

The importance of information on maternal health cannot be over-emphasized. As a major component in health promotion, health information play an important role by encouraging individuals to adopt health behaviour, to use health care services and to make informed decision about their overall health. Health information can be defined as an information seeking activity which makes individuals to know, to be motivated and to maintain healthy practices, and to make informed decisions about their own health (Redmond et al, 2010) in Tsehay (2014). Health information plays a big role on reproductive health, child health and promotes integrated management of childhood illness (IMCI), which includes management of five diseases of children under the age of five years: malaria, pneumonia, diarrhoea, measles and malnutrition (Silali, Maurice and Eunice (2013). Grason, Weisman and Silver (2002) noted that, individuals seek healthcare information from health professionals or community health workers, during chief‘s Barazas or health posters for reasons ranging from health awareness on primary health care, health promotion such as screening, curiosity to self-diagnosis and treatment. Clement et al (…) in Silali and Owino (2016) reported that ―Health information and capacity building help health seeking behaviours of individuals, the majority of maternal mothers feel empowered and more in control of their reproductive health and also address both 12 unmated and psychological needs of women at specific time of need. In prevention of mother to child transmission attempt in this era of HIV & AIDS pandemic, Hibbard et al, in silali and Owino (2016) noted that ―Health information empowers women to make informed choices and increase their perceptions in satisfaction of health provision towards primary prevention. Providing appropriate maternal information will empower mothers to act in an informed manner and to make right decisions that can transform their lives during pregnancy and after pregnancy and that of their new born. The provision of maternal health information during pregnancy is a compulsory and an important element of antenatal care (ANC) for every pregnant woman (Lincetto et al, 2006) in Nwangakala (2016). The basic maternal health information includes health information on nutrition and diet, family planning, pregnancy danger signs, breastfeeding, and labour and childbirth (WHO & UNICEF, 2003; Lincetto et al, 2006) in Nwangakala (2016). Hence, non-provision of health information to pregnant women limits their ability to manage pregnancy danger signs and up-keeping their health during pregnancy, childbirth and postnatal (Nwangakala, 2016). Pregnant women‘s access to health information and services is pivotal for a healthier population as it helps them take responsibility of their health and make better informed decisions about their health and that of their families (Henwood et al, 2003). The research show that well informed individuals are likely to take responsibility for their health (e.g. doing regular health check-ups, compliance to treatment and immunizations) and stay healthy for longer than their uninformed counterparts (Ransom et al, 2005; Gray et al, 2005; Wathen and Harris, 2007). Hence, there is the need for pregnant women especially first timers to have access to maternal health information so as to enable them to take informed decisions about their health and that of the family in general.

Maternal Health Services

Childbirth, even though a normal physiological process, has been associated with risks, which sometimes lead to loss of life. This fact is recognized and acknowledged in all cultures. Since the introduction of modern medicine, significant concern has been raised regarding the issue of improving maternal health services (MHS) to reduce morbidity, disability, and mortality due to pregnancy and the process of delivery (Umar, 2016). It is increasingly evident that improving maternal health service quality at the point of care can save the lives of many women and newborns (Tuncalp et al, 2015 cited in Beith et al., 2017). Maternal health is the health care that is provided to women during pregnancy, childbirth and the postnatal period. It also includes family planning, preconception, prenatal and postnatal care aimed at reducing maternal morbidity and mortality (WHO, 2010). The health care provided to a mother during pregnancy, delivery, and after delivery is important for the well-being and survival of both the mother and the child (Mungai and Oleche, 2016). Maternal health (MH) is therefore, a very important issue as women strive to live up to their potential as individuals, mothers, family members and citizens of a wider community. According to WHO (2015) ―By the end of 2015, 303,000 women will die of complications during pregnancy or childbirth.‖ Most of these deaths can be avoided as the necessary medical interventions exist and are well known. The key obstacle is that pregnant women lacks access to information on healthcare services that would enable them to access quality care before, during and after childbirth. Motherhood is the most important position a woman can have in her life but can be a life threatening event as well (Mungai and Oleche, 2016). During pregnancy, any woman can develop serious, life threatening complications that require medical care. However, it is well documented that 14 maternal morbidities and mortalities directly affect the well-being and survival of children and also contribute to poor family relationship (WHO, 2001). The risk of a woman in a developing country dying from a maternal-related cause during her lifetime is about 33 times higher compared to a woman living in a developed country (WHO, 2017). Some components of maternal healthcare Services, which have been found to have greatly reduced maternal morbidity and mortality, are described as antenatal care, postnatal care and delivery care. Maternal health service refers to all curative and preventive health services provided during pregnancy, birth and the postpartum periods at the primary or referral level. Pregnant women in the developing countries are at higher risk of losing their lives as a result of pregnancy related complications compared to their counterparts in the industrialised countries partly due to adherence to cultural practices that can neither promote health nor prevent diseases. This is made worse by the weak healthcare system that disenfranchises the rural and urban slum population even though they account for the large proportion of high risk pregnancies that result in the loss of life. It is important to note that more than 80% of all these deaths could be averted by simple, cheap and effective high impact components of maternal health services (WHO, UNICEF, UNFPA, and World Bank, 2010). Maternal health services (MHS) provide primary, secondary and tertiary levels of prevention to achieve better pregnancy outcomes. However, the use of prenatal and natal services among Nigerian women have been ranked among the lowest in the world and, consequently, the country is among the 10 countries with the highest maternal mortality ratio. Moreover, nationwide community-based studies on the use of maternal health services in Nigeria are limited (Umar, 2016). The function of the primary healthcare centre (PHC) is the provision of medical care and counseling services during pregnancy, 15 delivery and after birth that impacts on the survival of both mother and infant. Components of maternal health services include preconception care, antenatal care (ANC), intra-natal care, postnatal care and family planning. For the purpose of this study, the researcher concentrated on preconception, antenatal, intra-natal and postnatal care. Maternal health includes the health of women during pregnancy, childbirth and the postpartum periods. These services can be accessed from the primary, secondary or tertiary healthcare providers.

Primary health care:

Denotes the first level of contact between individuals and families with the health system. According to Alma Atta Declaration of 1978 ―Primary healthcare was to serve the community it served; it included care for mother and child which included family planning, immunization, prevention of locally endemic diseases, treatment of common diseases or injuries, provision of essential facilities, health education, provision of food and nutrition and adequate supply of safe drinking water.

Secondary health care

Refers to a second tier of health system, in which patients from primary healthcare are referred to specialists in higher hospitals for treatment.

Tertiary health care

Refers to a third level of health system, in which specialized consultative care is provided usually on referral from primary and secondary medical care to specialized intensive care units (SICUs), advanced diagnostic support services (ADSS) to specialized medical personnel (SMP) on the key features of tertiary health care. Most of these maternal deaths can be prevented. Research shows that approximately 80% of maternal deaths could have been averted if women had access to essential maternity and basic health-care services (UNICEF, 2008). One factor in the utilization of maternity care services, especially in Africa, is the cultural background of the woman. The cultural perspective on the use of maternal health services suggests that medical need is determined not only by the presence of physical disease but also by cultural perception ofillness (Onasoga, Osaji, Alade and Egbuniwe, 2014). In most African rural communities, maternal health services co-exist with indigenous health care services; therefore, women must choose between the options (Onasoga, 2014). The use of modern health services in such a context is often influenced by individual perceptions of the efficacy of modern health services and the religious beliefs of individual women. Gaston (2014) is of the opinion that in rural communities, where a large component of the people originates from traditional societies (hereafter referred to as indigenous people), government and health workers tend to provide information on services that have been implemented successfully in other contexts. They emphasize the need for the sharing of such information in the belief that they could be applied to solve or alleviate similar problems in rural areas as well, but very often the context from which the information products or services originated tend to differ from the cultural context of the target groups. Contexts, as referred to here, can include cultural environments, organizations, tasks, circumstances, systems, technology, and formal or informal settings. The common factor that runs through all of them is that they have boundaries that exercise some form of control regarding the flow and use of information or the extent of interaction that is allowed between the context and the outside world. Within the boundaries, sets of rules regarding standards, norms and values govern the handling of information (Audunson, 1999) and determine what type of information is acceptable or whether resistance towards information will take place or not.Providing appropriate maternal information will empower mothers to act in an informed manner and to make right decisions that can transform their lives during pregnancy and after pregnancy and that of their new born. Akaligaung (2015) noted that improving maternal healthcare service delivery (MHCSD) for better health outcomes for women of reproductive age and children under 17 the age of five is central in achieving MDG 4 and 5. It is globally acknowledged that the use of quality improvement (QI) is one of the key drivers to meeting these goals. Quality improvement (QI) in the provision of maternal and child health services such as the availability and accessibility of midwives, training of QI teams, incentive packages for providers and clients, community support groups, and PFA(Pension Fund Administrator) partners were key contributory factors.

The policy project (n.d) noted that services for safe motherhood should include: 

• Family planning, counseling, information and services 
• Health care before, during and after childbirth 
• Skilled assistance during delivery 
• Care for obstetric complications, including emergencies 
• Health education for women, adolescents, and communities, and  Services to prevent and manage the complications of unsafe abortion.

Maternal health services are provided so as to increase the proportion of births delivered under medical attention to reduce the health risk of pregnancy and childbirth. Basically, maternal health services are provided during antenatal care (ANC), delivery care (DC) and postnatal care (PNC). ANC refers to pregnancy-related healthcare provided by a health worker either in a medical facility or at home. In theory, ANC should address both the psychosocial and medical needs of women within the context of the health-care delivery system and the surrounding culture (WHO, 1996). ANC has two major functions. First, antenatal health check-ups facilitate early detection of several complications such as high blood pressure and malnutrition. Second, antenatal visits play a crucial role in preparing a woman and her family for birth by establishing confidence between the woman and the healthcare provider and by individualizing promotional 18 health messages (WHO, 1996). The aim of ANC is to identify and commence early management of high risk pregnancy. The goal of ANC is to have healthy pregnancy, clean and safe delivery, and to give birth to a full term healthy baby. The components of ANC includes registration and record keeping, periodic examination (including laboratory tests, risk detection and management), immunization, referral as needed, emotional and psychological support, health education, nutrition care, dental care, home visiting and social care (MOHP, 2007) in Azza (2015).

The purpose of antenatal care is to: 

• support and encourage psychological adjustment to pregnancy, childbirth, breastfeeding and parenthood 
• promote awareness of the social and psychological components of childbearing and their influences on the family 
• monitor the progress of pregnancy to ensure the health and wellbeing of mother and fetus 
• monitor all women for signs of obstetric difficulties through close personal attention and diagnostic tests where essential and indicated recognize deviations from the normal, and treat or refer as required recognize that women who develop warning signs may return to normal following treatment and might not necessarily be continued to be regarded or treated as at risk 
• build a trusting relationship between the woman and her care givers provide the woman with information with which she can make informed decisions 
• actively involve relevant members of the woman‘s family or friends in the experience of pregnancy, encouraging the supportive role that they might play and recognizing that they too might need support.

Thus, the recommended content of ANC service provision has three main components:

1. Assessments – includes history-taking, physical examination and laboratory tests to identify problems of risk factors.
2. Health promotion – includes advice on nutrition, birth planning, information about danger signs and contingency planning, subsequent contraception and breastfeeding. 3) Care provision – includes iron and foliate supplements, tetanus toxic immunization, psycho-social support and record keeping. Antenatal care provides an opportunity for a variety of preventive interventions for pregnant women, including immunization, nutrition, education and counselling about their plans for delivery and postpartum family planning. It also allows women who meet known risk criteria to be identified and monitored and subsequently referred to the appropriate centres for delivery care. Ideally, pre-existing and new medical problems such as malaria, anaemia and syphilis can also be detected and managed during antenatal care visits. It is also during such visits that providers can develop rapport with women, making them more likely to seek assistance during labour and delivery, should an emergency occur. The mother‘s health condition during pregnancy significantly determines the health outcome of the pregnancy as well as mother and child‘s health after delivery. Comprehensive utilization of antenatal care during pregnancy reduces the likelihood of adverse health outcomes caused by pregnancy related complications ((Bloom et al, 1999). Antenatal care is the type of preventive care that provides regular check-ups for pregnant women with the aim of preventing, detecting and treating pre-existing conditions and 20 potential health problems throughout the course of pregnancy (McDonagh, 1996; Bloom et al, 1999; Lawn and Kerber, 2006). Antenatal care services includes identification and management of obstetric complications e.g. preeclampsia, Tetanus toxoid immunization, intermittent preventive treatment for malaria and identification and management of infections such as HIV, syphilis and other STIs (Lawn and Kerber, 2006). Hence, the more the woman adhere to antenatal care visits, the higher her chances of having better pregnancy outcomes as she is more likely to deliver under skilled attendants and receive the required obstetric care (Chakraborty et al, 2003; Vanneste et al, 2000; Yanagisawa et al, 2006; Nikiéma et al, 2009) in Nwangakala (2016).

Preconception Care

Maternal health refers to the health of the mother during pregnancy, childbirth and the postpartum periods (Dairo and Owoyokun, 2010). The Centre for Disease Control has defined preconception care as ―Interventions that aim to identify and modify biomedical, behavioral and social risks to a woman‘s health or pregnancy outcome through prevention and management by emphasizing those factors that must be acted upon before conception or early in pregnancy to have maximal impact.‖ Preconception care is the care a woman receives before she gets pregnant to help promote a healthy pregnancy. Taking steps to make sure a woman is healthy and avoiding exposure to harmful behaviors and toxins before she conceives can decrease the chances of problems during pregnancy and improve the health of her child.According to WHO (2013) ―Preconception care has a positive effect on a range of health outcomes. Among others, preconception care can reduce maternal and child mortality, prevent unintended pregnancies, complications during pregnancy and delivery, still births, preterm birth and low birth weight, birth defects, neonatal infections, underweight and stunting, vertical transmission of HIV/STI‘s. It also reduces the risk of 21 some forms of childhood cancers, type 2 diabetes and cardio-vascular diseases in later life. Preconception care is the care that you receive before you get pregnant. It involves finding and taking care of problems that might affect you and your baby later, like diabetes or high blood pressure. It also involves steps you can take to reduce the risk of birth defects and other problems. For example, you should take folic acid supplements to prevent neural tube defects (Medline plus, 2015). Even where strong public health programs are in place across the life-course, they do not guarantee that women enter pregnancy in good health. Preconception care is defined as a set of interventions that aim to identify and modify biomedical, behavioral and social risks to the woman's health or pregnancy outcome through prevention and management. Certain steps should be taken before conception or early in pregnancy to maximize health outcomes. The American College of Obstetricians and Gynecologists (ACOG) recommends that all health encounters during a woman's reproductive years, particularly those that are part of preconception care, should include counseling on appropriate health behaviors to optimize pregnancy outcomes and prevent maternal mortality. Schmitt (2012), is of the opinion that a woman should start taking care of herself before she starts trying to become pregnant. This is called preconception health. It means knowing how health conditions and risk factors could affect you or your unborn baby if you become pregnant. For example, some foods, habits, and medicines can harm your baby — even before the baby is conceived. Some health problems also can affect pregnancy. Talk to your doctor before pregnancy to learn what you can do to prepare your body. Women should prepare for pregnancy before becoming sexually active. Ideally, women should give themselves at least 3 months to prepare before getting pregnancy.

• Prenatal Care:

Prenatal care is perhaps the most important factor which determines the outcome of pregnancy. It has long been endorsed as a means to identify mothers at risk for delivering a preterm infant and to provide an array of available medical, nutritional, and educational interventions to reduce the risk of low birth weight and other adverse pregnancy conditions and outcomes. Today, prenatal care typically is initiated in the first trimester of pregnancy and has an increasing schedule of visits as the pregnancy progresses. The content of this care usually includes screening for a variety of medical conditions, physical examinations and educational or counseling services. Preconception care provides similar aspects, but instead targets all women of reproductive age, during adolescence and before the first pregnancy, and between pregnancies. Prenatal care is the care a woman gets during pregnancy. Prenatal care should begin as soon as a woman knows or suspects that she is pregnant. Early and regular prenatal visits with a health care provider are important for the health of both the mother and the foetus. Prenatal care is important to help promote a healthy pregnancy. Women who do not seek prenatal care are three times likely to deliver a low birth weight infant and lack of prenatal care can also increase the risk of infant death (women‘s health 2012). Prenatal care is an important part of basic maternal health care because these visits may be a woman‘s first interaction with the health system. They are an important opportunities to assess her overall health, and to speak with her about her sexual and reproductive health and rights. Even though a great majority of complications arise with little or no warning among women who have no risk factors (UNIFPA 2012), this particular care is not common to individuals even in the urban areas.

Antenatal Care (ANC)

Antenatal care is the care received during pregnancy from skilled health personnel such as the goal oriented model recommended by the WHO which include 4-5 visits for pregnant women who are not having medical problems (Dairo and Owoyokun, 2010). There is documented evidence of a national policy and/or Ministry of Health (MoH) guidelines for a recommended minimum package of services to be provided by antenatal care (ANC) facilities. Variations exist among recommended essential and minimum care packages, and can be attributed to the types of health risks prevalent in different settings (for example, areas of endemic malaria or generalized HIV epidemic). For women whose pregnancies are progressing normally, WHO recommends a minimum of four ANC visits, ideally at 16 weeks, 24-28 weeks, 32 weeks and 36 weeks (USAID/Population Council, 2006). It is recommended that expectant mothers would receive at least four antenatal visits, in which a health worker can check for signs of ill health – such as underweight, anaemia or infection – and monitor the health of the fetus (Schmitt 2012). During these visits, women are counseled on nutrition and hygiene to improve their health prior to, and following, delivery. They can also develop a birth plan laying out how to reach care and what to do in case of an emergency. Despite the importance of antenatal care to predict and prevent some complications, many are sudden from the onset, and unpredictable. In the primary health care settings, women learn the health benefits of spacing births and how to plan their families. They are also counseled on newborn care and the importance of birth registration. While antenatal visits may not prevent complications, women who receive antenatal care are more likely to deliver with the help of a skilled birth attendant, who can recognize and address these issues. According to WHO, ―Preventing problems for mothers and babies depends on an operational continuum of care with accessible, high quality care before and during pregnancy, childbirth, and the postnatal period. It also depends on the support available to help pregnant women reach services, particularly when complications occur. An 24 important element in this continuum of care is effective ANC.‖ The goal of the ANC package is to prepare for birth and parenthood as well as prevent, detect, alleviate, or manage the three types of health problems during pregnancy that affect mothers and babies. These are:

• Complications of pregnancy itself 
• pre-existing conditions that worsen during pregnancy and 
• Effects of unhealthy lifestyles.

Antenatal care (ANC) is very vital because all pregnant women are at the risk of developing complications and because many of these complications are unpredictable, it is important to ensure that all pregnant women have access to preventive interventions, early diagnosis and treatment for problems, and emergency care when needed. It is now emphasized that ANC should focus on early detection and skilled, and timely interventions for factors having proven impacts on maternal and infant outcomes (Maternal and Neonatal Health Program, 2001a). The strength of ANC, therefore, lies in its role for early identification of complications; and provision of information on danger signs and how to handle them (Yuster, 1995, cited in Adamu, 2011). Antenatal care also makes it possible to screen for sexually transmitted diseases such as HIV infection, which is known to have taken its toll in much of the developing world (Adamu, 2011).

Delivery Care

The aim of global safe motherhood programme in 1987 was to ensure that the outcome of every pregnancy is a healthy mother and a healthy newborn. Attendance by a medically trained person during labour and delivery can facilitate such referral and is one goal of the safe motherhood initiative. An important indicator of health service coverage is the proportion of births delivered in a health facility where obstetric complications can be managed (Koblinsky et al., 1995; Maine et al., 1995).There‘s a possibility that a delivery may have complications, the emphasis is to promote the use of skilled and trained delivery care providers and to ensure that all women have access to life-saving emergency interventions at the time of labor and delivery. In many countries, deliveries occur at home attended by traditional birth attendants (TBAs). Previously, there were extensive efforts and funds expended toward upgrading the skills of TBAs, but safe motherhood program initiatives have concluded that, in almost all cases, ―the level of skill among ‗skilled birth attendants‘ is lower than it is ‗safe‘ for safe motherhood. It is also noted that in-service training cannot improve the skill level of trained providers to the level of competency desired in all skills‖ (Maternal and Neonatal Health Program, 2001). With this conclusion, there is a shift in the definition of qualified delivery providers to ―Persons with midwifery skills who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose and manage or refer complicated cases‖ (Koblinsky, 2000).

Post Natal Care (PNC)

Post-natal care, provided in the six weeks following delivery, is as important as antenatal care. Bleeding, sepsis and hypertensive disorders can all take place after a woman has exited the health centre. And newborns are also extremely vulnerable in the immediate aftermath of birth (UNIFPA 2012). The post-natal period (or called postpartum, if in reference to the mother only) is defined by WHO as the period beginning one hour after the delivery of the placenta and continuing until 6 weeks (42 days) after delivery. According to WHO (1998), ―Postnatal care is the care of mom and the baby immediately after childbirth.‖ The period following the birth of the child is called the 'postnatal period'. Postnatal care is essential to save the life of the mother and her newborn. Knowledge on the determinants of postnatal care assists the policy makers to design, justify and implement appropriate interventions. Khanal, Adhikari, Kankee andGavida (2014) defined postnatal period as the time immediately after the birth of the baby and up to six weeks (42 days) after birth. It is a critical period for the newborn and the mother. Immediately after birth, bleeding and infection pose the greatest risk to the mother‘s life, while preterm birth, asphyxia and severe infections pose greatest risk to newborn. According to Ugboaja, Berthrand, Igwegbe and Obi-Nwosu (2013), the days and weeks following childbirth called the postnatal period is a critical phase in the lives of mothers and newborn babies. Major changes occur during this period which determines the well-being of mothers and newborns. Yet, this is the most neglected time for the provision of quality services. Lack of appropriate care during this period could result in significant ill health and even death. Rates of provision of skilled care are lower after childbirth when compared to rates before and during childbirth. Most maternal and infant deaths occur during this time. According to WHO (2014), postnatal care is among the major recommended interventions to reduce maternal and newborn deaths globally. This intervention enables skilled health professionals to dictate postpartum problems and potential complications and provide prompt treatment. Despite the beneficial impact of postnatal care, most women do not attend postnatal care services. It is, therefore, pertinent to understand the factors influencing the decisions not to seek postnatal care. A clear understanding of these factors will provide a policy tool for the development of community interventions that will increase the use of postnatal care services. It is important for mothers to receive PNC within the first forty days after birth as it has been recorded that more than 60% of maternal deaths take place during the postnatal period (Gill et al, 2007). PNC also provides an opportunity to counsel the new mother on family planning and caring for herself and her newborn, as well as to assess the 27 newborn for any problems. In developing countries, the most common causes of maternal deaths during the postpartum period are hemorrhage, infections and hypertensive disorders (Li et al, 1996 cited in Adamu, 2011). However, accessing PNC is the only way of solving maternal death. More so, it has been reported by Population Council (2010) that less than 30% of women in developing countries access or receive care or medical follow-up in the period immediately following childbirth. In December 2012, the UN General Assembly adopted a resolution urging governments to move towards providing all people access to affordable quality healthcare services, including primary care and maternal health services. Primary care saves lives from the provision of maternal care, immunizations and newborn health to a consistent supply of sexual and reproductive health services (United Nations, 2013). According to WHO (2013), a woman reduces the risk of pregnancy related diseases and complications when she visits and utilizes antenatal healthcare services within the first trimester of her pregnancy. Averagely, the WHO (2013) suggests that every pregnant woman visits and receive ANC services from a qualified person (approved health professional) four times before delivery. This supports the assertion that the healthcare that a pregnant mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child (GDHS, 2008). In this regard, utilization of antenatal healthcare services is paramount to reducing maternal mortality globally, within Sub-Saharan Africa and Northern Nigeria in particular. Moreover, the access and use of MHS was reported to be low for women living in communities without appropriate health facility because of the interactions between transport fare, and cost of fees for services to be rendered (Fatso et al., 2008, 2009). Studies in Ghana (Hagman, 2013); Kenya (Desai et al., 2013 and Essendi et al., 2011) and 28 Nigeria (Babalola and Fatusi, 2009; Ebuehi and Akintujoye, 2012; Onah, Ikeako and Iloabachie, 2006) have indicated that the institutional and technical competence of a health facility that provides MHS services is a major consideration among women irrespective of their social status. The under use of MHS is commonly seen among rural women in developing countries generally and African countries in particular. Rural women are largely dependent on their spouse and other family members for financial support, and most of them do adhere to the norms and traditions that stressed the authority of husband over their wives (Adamu and Salihu, 2002; Idris et al, 2006; Magoma et al., 2010). A community based study in Nigeria reported that nearly half of all participants cited the lack of use of modern health services, distance, and the need to have other members of the family to accompany the sick or pregnant women increase the overall cost in terms of transportation fare, feeding and hospital charges (Ayeni, 1987). Nnadi and Kabat (1984), in an extensive national survey on the choice of health services amongst the Igbos, Hausas and Yorubas; the 3 major ethnic groups in Nigeria, constituting about 50% of the Nigeria‘s population, reported that individuals who lived near modern health facilities have higher use rates for both urban and rural clients. Other factors reported in Nigeria, that are responsible for low ANC attendance and hospital deliveries include, the perceived quality of service and the supposed family members to take decision on health matters, particularly in the north-west(Harrison,1983;oche etal.2010,Umaretal2011).

Types Of Maternal Information Services

Audra Wellington (2017), noted that with the increasing number of chronic conditions such as obesity, hypertension and bad life-style choices many women do not start their pregnancy with a clean bill of health. These are the women who are in most need of case management, primary care and other services to bridge the gap between health and social disparities. This gap could be bridged with the provision of adequate maternal health information (MHI). Mvula (2010), in an investigation of health and nutrition messages passed to pregnant women reported that all the nurses (100%) said that they measured the weight blood pressure as well as physically examined the women and conducted health talks. The nurses also said that they had personal chats with the women. In comparison, 58% of the women said they were physically examined on the belly and another 53% said they had their weight measured. The women also mentioned other services that were provided to them which included HIV testing and immunizations. Some women (37%) also said that they had attended health talks. Despite the fact that 93% of the pregnant women received iron supplements, only 7% mentioned it as part of routine service provided. These were 30 pregnant women who were between 15 to 19 years of age and were living within 1 to 5 km from the hospital.

Awareness Of Maternal And Child Health Information

In an information-seeking situation, awareness refers to the information seeker being aware of various aspects of the searching and sense-making processes, including the task and its context, past and present actions, and various attributes of the information objects and the system. Awareness is one of the most important issues that is identified and addressed in the computer-supported cooperative work (CSCW) literature. One of the questions often asked about awareness in CSCW is ―The awareness of what?‖ (Schmidt, 2002) argued that we should talk about awareness not as a separate entity, but as somebody‘s being aware of some particular occurrence. In other words, the term awareness is only meaningful if it refers to a person‘s awareness of something. Heath, Svensson, Hindmarsh, Luff and Lehn (2002) suggested that awareness is not simply a state of mind or a cognitive ability, but rather a feature of practical action, which is systematically accomplished within developing course of everyday activities. Shefner-Rogers and Sood (2004) reported that the involvement and participation of the community in maternal health activities, increases their knowledge and awareness of danger signs in pregnancy. Community awareness of maternal health problems was evident following exposure to maternal health education (Manandhar 2004; Ogwang et al. 2012). Most community members obtained their maternal health education through health campaigns and activities in the community. Maternal health campaigns usually provide education through multimedia and support from health workers within the community. Multimedia campaigns (television, radio, print leaflets and posters), impart new knowledge about maternal health and the danger signs in pregnancy (Shefner-Rogers and Sood, 2004). Perreira (2002) also suggests that education, communication and information from health professionals, either in the community or in health the centres, increased the knowledge of the community and engages them in being alert to maternal health problems and carrying out birth preparation activities in order to reduce maternal death. Perreira‘s (2002) case study identified those women who were exposed to maternal health education both in maternity clinics and in the community who successfully improved their knowledge and awareness of the danger signs in pregnancy. Although the study did not provide information on which of these two settings was more effective in imparting information, education and communication on maternal health and the danger signs in pregnancy, the campaign during maternal health programmes effectively increased the knowledge and awareness of maternal health in the community. Some studies were carried out on the involvement of the community in maternal health activities and the impact on the increase in knowledge and awareness of maternal health. The involvement of family members and participation of the community in maternal activities increased knowledge (Mullany et al. 2006; Abdulkarim et al. 2008), and increased awareness of the danger signs and obstetric problems in pregnancy (Perreira 2002; Manandhar 2004; Shefner-Rogers and Sood 2004; Ogwang et al. 2012). Most of the studies related to this topic were conducted in various countries, including Indonesia. These studies highlighted the knowledge gained after the involvement of the community in maternal health activities. The involvement of family members such as husbands in antenatal care increased their knowledge of maternal health and birth preparation (Mullany et al. 2006; Steen et al. 2012). Engaging the community could also contribute to help the women to access maternal health services, improve knowledge on the causes of maternal mortality and prevent maternal deaths in the community (Abdulkarim et al. 2008; Ogwang et al. 2012). 32 Studies conducted by Mullany et al. (2009) identified the importance of involving husbands during pregnancy and childbirth in order to successfully improve women‘s knowledge and awareness of their maternal health. A randomised controlled trial (henceforth RCT) by Mullany et al. (2009) on the impact of including husbands in antenatal health education in maternity practice in Nepal provided strong evidence in the intervention group. This group was made up of women and their partners who reported making birth preparations, and being more likely to attend the antenatal and postnatal care during pregnancy and childbirth; compared to the control group whose husbands were not included. This study provided a strong and thorough analysis of each step of the intervention. One of the main challenges in an RCT study is having an adequate intervention, as a lot of effort is required to transfer knowledge into action (Jadad, 1998). Once the interventions were applied in the group, the study outcome showed the positive impact of involving male partners in antenatal health education during maternal healthcare. These studies (Perreira 2002; Manandhar 2002; Shefner-Rogers and Sood 2004; Ogwang et al. 2012) also indicate that an increase in birth preparation activities follows an increase in knowledge of maternal health. An evaluation study conducted by Ogwang et al. (2012) observed that the community emergency support intervention programme on maternal health in Uganda had successfully created awareness in the community about maternal health, and further actions were undertaken when obstetric emergencies occurred. These actions included the provision of transportation and the referral of women to the nearest health facilities. This study provided a clear explanation of the community context, which was beneficial for the sustainability of the programme. Some other studies on maternal health programme evaluations (Perreira 2002; Manandhar 2004; Shefner-Rogers and Sood 2004) have also successfully provided evidence about actions 33 to promote maternal healthcare after the health programmes were implemented. However, most of these studies were conducted only a few months after the maternal health campaign was carried out and education was provided. This short period after the campaign may not have been enough to fully capture changes in the knowledge and behaviour of the community and family members (Shefner-Rogers and Sood, 2004). Further research into how this knowledge and behaviour could be applied in the community during pregnancy and childbirth is still to be carried out. Mullany et al (2006) and Steen et al (2012) in their studies reported that the involvement of family members such as husbands, in antenatal care increased their knowledge of maternal health and birth preparation. This study provided a strong and thorough analysis of each step of the intervention. One of the main challenges in an RCT study is having an adequate intervention, as a lot of effort is required to transfer knowledge into action (Jadad, 1998). Once the interventions were applied in the group, the study outcome showed the positive impact of involving male partners in antenatal health education during maternal healthcare.

Sources On Maternal And Child Health Information

In recent years there has been increased interest in both developed and developing countries on population‘s access to health information (Anasi, 2012). More people are searching for health information on different health issues (Fox, 2005 in Nwangakala (2016). Patients‘ lack of adequate health information from their care providers caused them to seek information from other sources such as internet and printed materials. Maternal and child health information forms the cradle of human right that allows mothers to access quality and reliable health care hence, decrease morbidity and mortality rates, aimed to be achieved in global goals number 3 and 17 of 2015 by 2030. Globally, over 80% of community households have limited access to effective, reliable, efficient 34 and quality maternal and child health information, especially in Sub-Saharan Africa. They depend solely on health professionals and community health workers (CHWs) as their main sources of health information, with large diversified society of demographic, socioeconomic and socio-cultural factors. Studies indicate that individuals engaging in health information-seeking are more likely to have better health knowledge, feel more comfortable and confident when dealing with personal issues with health professionals and they demonstrate higher levels of health promotion activities than people who do not look out for health information (Shieh et al.2001; Buseha et al., 2002) in Tsehay (2016). Providing health information is considered to be an important component by maternal health information providers and the maternity information may guide women in their decision making processes towards their health and the health of their children (Shieh et al, 2001 in Tsehay, 2016). To this end, knowing their information needs and sources of maternity information plays a paramount role. Research documents such as books,journals, videos on maternal health that pregnant women have various information needs and sought various kinds of information sources to satisfy their health information needs during pregnancy. Currently, there is a wide range of health information resources produced by different types of providers to disseminate health care information to consumers and to guide health behaviours (Nicholson et al., 2003). When seeking specific kinds of information, some women are engaged in a range of channels. Whereas others confine themselves to a more restricted few channels, others do not. Relatively speaking, as Grimes et al (2014) contended, the woman's ability to access wide range of variety sources can be highly impacted by the access she has to different sources and her ability to comprehend the available information. Thus, beyond creating access to information, knowing their choices and understanding their health literacy level could play a vital role 35 in meeting their information needs effectively (Grimes et al, 2014). Roxanne (2004) in a study is of the view that individuals who receive information from multiple sources have a better chance of paying attention to the information being provided and taking actions to improve their health status. The pregnant women reported that TBAs and mother-in-laws were their primary sources of maternal health information. However, because there were health facilities in the study population that offers maternal healthcare services, the researcher wanted to know if the women also sought maternal health advice/information from the skilled care providers or if they were offered the health information when they went for ANC visits. Majority of the women claimed that they were not offered any maternal health information or health education at the health facilities. Interestingly, in a survey carried out by Wafula (2007) in Silali and Owino (2016), in Kenya in Trans-Nzoia and Umlalazi districts in South Africa on the sources of health information among rural women, results showed that family and friends were the main sources of maternal health information in Kenya. In contrast, Silali and Owino (2016) in their study found out that family and friends were the least sources of maternal health information. Aaronson et al, (1988) in Uloma and Adedotun (2013) revealed that women in the United States of America often look for pregnancy related information from health care providers and books. As their investigation indicates, health care providers and books were preferred by the majority of women as their first and second most important sources of information. The research also examined the relationship between information sources and the socio-economic status of pregnant women and revealed that women of higher socio-economic status relied more on books and less on family than did women of lower socio-economic status. 36 Similarly, Lewallen (2004) examined the health behaviour and sources of health information of low-income pregnant women living in the South Eastern United States of America in the research and confirmed that women learn more about health behaviour from interpersonal sources. That is, among family members while mothers were identified as a single and a major information source about health pregnancy issues. Additionally, other interpersonal sources like health professionals and physicians were sources often consulted by women. The study further mentioned written and audio as information sources were also sought by women. An investigation by Davis and Flannery (2001) on the health information delivery systems for Puerto Rican women reported that health information was accessed through informal and formal settings. These wide ranges of information obtaining settings were regarded as major sources of health information for Puerto Rican Women. Among the selected information obtaining channels, obtaining information from friends, remedies handed down through word of mouth, childbirth classes and health care settings are few to mention (Davis and Flannery, 2001). Interestingly, the research showed how cultural values were enshrined in the Porto Rican health information seeking culture and the meaning of health information was developed through the lens of Puerto Rican culture. A Puerto Rican family member who spoke in Spanish was perceived as a trustworthy source of health information (Davis and Flannery, 2001). Whereas interpersonal sources that do not speak the language and were strangers to them were considered to be non trustworthy sources (Davis and Flannery, 2001).Any source of information that doesn‘t use the language of the recipients to fully express the particular information, then the recipient can‘t accept it as credible. There are also researches that documented the maternal information needs and sources of information on women residing in Africa (Tsehay, 2016). 37 Nwagwu and Ajama (2011) examined the health information needs, sources and information seeking behaviour of women living in rural Nigeria. Using data collected through focus group discussion and a questionnaire, the research revealed that women owned and used radios more than other sources, and they sought health information mainly for themselves and their children. Providers often disseminate health information using the health education sessions and pregnancy follow-up visits in which most of the women participated (Naanyu et al., 2013). Davies and Bath (2002) explored the interpersonal sources of health and maternity information for Somali women living in the UK. The study revealed that women referred and used information from a wide range of interpersonal sources. Accordingly, most of the women highly relied on information from general practitioners and from information sought during health visits as their primary sources and they also consulted information sources like friends and neighbours. However, the women preferred community health forums organized by health professionals whereby professionals were invited to address different kinds of health issues. Furthermore, informal interpersonal health sources which were considered to be an easily accessible way by women provided the means through which further information were consulted and referred. Although information on maternal health issues were provided by a wide range of channels, the ability to chose and the tendency to use sources of maternity information can be determined and affected by different factors. Carol Shieh et al., (2009) examined the influence of health literacy on health information seeking behaviour of low income pregnant women in the United States. The study noted that low health literacy in childbearing women affected the women‘s pregnancy knowledge and potentially the health of their babies. Pregnant women who had low health literacy level were found to have had more personal barriers to information 38 seeking than women who had high literacy level. Thus, using interventions that promotes the information-seeking skills and creates an access to information may be helpful for women who have low health literacy (Shieh et al., 2009) in Tsehay (2016). Owino (2016) reported that respondents who were educated up to secondary and tertiary levels mostly preferred health professionals at (59.0.0%) and (50.0%), respectively, as their main source of information followed by Community Health Worker and at (25.6%) and (25.0%), respectively. Level of education, statistically, significantly influenced the choice of source of quality maternal and child health information (P value .0.5, 95% CI 3.3, 8.1). Silali and Owino (2016) in their study reported that most of the women who delivered in hospitals got information from posters (77.8%), followed by those who got information from the churches (76.9%). Those who got information from health facility were (74.2%) whereas those who obtained the information from community health workers were (59.4%). Media source was used by (58.8%) of the respondents, the least source used by women who delivered in hospital (50%) was mobile publicity events. The chance of getting information from place of delivery was more reliable with (P value 0.3, 95% CI 2.0, 3.8) Ogunmodede (2013) submitted that health information is a vital resource for individuals who seek information for as varying reasons as mere curiosity, self-diagnosis and analyzing and evaluating treatment for health. In the past, formal sources of information were books and newspapers which dated back to nearly a century but nowadays means of transmitting information has increased with a variety of electronic media for interactive health communication (for example, the Internet, CD-ROMs, and personal digital assistants [PDAs]) which can serve as sources of individualized health information, reminders and social support for health behaviour change (Case, 2007). These new technologies may also connect individuals with similar health concerns around 39 the world. Then there are also informal sources such as family and friends whereby people interact verbally to get information about some health issues. Although government is aware that information can lead to the understanding of rural women on maternal health services, its focus seemed to be more on the provision of the service itself rather than knowing the information needs, seeking and using health information by the mothers who are supposed to utilize these services. A project of this kind will only be successful when cultural and religious values of the beneficiaries are being respected. It is in this regard that Idris et al (2013) states that there is the need for local studies to generate information that is necessary for planning and implementation of public health programs in manners that take individual local peculiarities into consideration. The researcher wants to use the skill of collecting, organizing, storing, retrieving and disseminating information to solve these problems, thereby using information as a resource that can be applied to improve the quality of people‘s lives and avert these maternal deaths.

Access To Maternal And Child Health Information

For nearly half a century it has been said that we inhabit a knowledge or information society. Today‘s information society is different from the industrial society of the early 1900s in that the global economy is now heavily affected by information whereas 100 years ago it was primarily influenced by production of goods. As information and information services have taken on an increasingly important role in this economy, in order for individuals and groups to fully participate we require access to the kind of information that grants full enfranchisement and economic integration. This information access includes not only the ability to obtain information but also the ability to use the information obtained Whitely (1994). 40 Information access according Thompson and Afzal (2011) can be thought of as a continuum beginning with information acquisition and culminating at information use. Information access begins at a point where a user comes into contact with information. Lack of information access will greatly determine the extent to which a group can be considered information rich or poor. It can be argued that information access and information poverty have a close association; thus information poverty has been defined by chatman (1996) as ―A lack or scarcity of information about resources or opportunities available within and outside one‘s community‖ and information-poor as individuals who ―perceive themselves to be devoid of any sources that might help them.‖ Access means that information and services are available and within the reach of women who need them. Clients need to receive information and counselling on their health and health needs in order to make timely informed decisions about their reproductive health. Wolfson (2006) reported that studies has shown that access to quality health care information leads to real improvements in reproductive health. Solid information and positive interaction between client and provider can contribute to client confidence and compliance. Evidence supports the idea that women who are given the power and information to make decisions can save their own lives in cases of obstetric emergencies. For example, in India, the Rural Women‘s Social Education Centre undertook an intensive health education campaign covering more than 20,000 rural poor agricultural labourers. The campaign identified pregnant women, who were then given health advice and encouraged to deliver in the hospital. A series of workshops and pamphlets explained the process of childbirth, appropriate self-care and danger signals in pregnancy. As a result, three-quarter (76%) of those with complications such as prolonged or obstructed labour, heavy loss of blood during labour or postpartum, and hypertensive disorders of pregnancy, delivered in the hospital (Sundari, 1993). In 41 rural Bangladesh, pictorial cards were used to raise community awareness about the complications of pregnancy and childbirth and to encourage women to use health facilities in emergencies. Pregnant women who received a pictorial card were more likely to use institutional facilities for the management of their obstetric complications compared to those who did not receive the cards (Khanum et al., 2000). When information practices are understood to be shaped by social context, privilege and marginalization alternately impact not only access-to but also use-of information resources. People respond to information by seeking for more information, also by sharing or spreading information, creating documents, telling other people (krikelas 1983; wilson 1994;haythornthwaite 1996; Williamson 1998; Pettigrew; roux) and also by taking mental notes.Avoiding or ignoring information, hiding and/or destroying information, disputing or disbelieving information (Chatman, 2000 in Godbold, 2006) Good quality services require health care providers to have adequate clinical skills and to be sensitive to women‘s needs. Facilities are required to have necessary equipment and supplies, and referral systems to function well enough to ensure that women with complications get essential treatment. Advocates can work to increase women‘s access to information or work to remove operational constraints in providing effective services.Studies have shown that women of reproductive age in Africa are still not given opportunity to make their own decisions as most of them have low education level and considered low status in the society compared to men.( UNICEF 2008) This has made it difficult for the women of reproductive age from Sub-Saharan Africa to access maternal health information effectively hence the lack of knowledge on maternal health services and these justifies reasons for high maternal mortality in most of the African countries (Magadi, Madise and Rodrigues, 2000 in Sila and Owino, 2016). Erica (2008) in Sila and Owino (2016) in a study reported that low status of girls and women denied them the power to make decisions that affected their reproductive health.

Barriers To Maternal And Child Health Information

Illiteracy and access to knowledge are two of the key problems that inhibit socioeconomic development in developing countries. Rural women of reproductive age lack the vital or basic maternal health information they need to improve their health, and because most of them are illiterate, they cannot benefit from many educational methods. Furthermore, lack of electricity and poor roads isolate them in accessing various sources of maternal health information. In Ghana according to a non-governmental organization which conducted a pilot test on the use of talk book in accessing health information in rural area in northern Ghana observed that most of these Organizations travel to villages where they share knowledge about health but fail to consider the population reached The method of delivering information is expensive it cost US$20-$40 per trip. It is also inefficient because each visit occurred infrequently and covers various topics causing many community members to forget information that is not immediately applicable to them. This scenario calls for improvement to access to health knowledge to the rural 43 woman, due to the fact that the rural woman of reproductive age has low or no education hence higher percentage in poor health status compared to urban women. In Nigeria one in 10 women read newspaper weekly compared with three in ten men . This implies that most women of reproductive age have limited access to sources of maternal health information. Poverty can inhibit or is a barrier to non utilization of maternal health services. For instance National Partnership for Women and Families (2018), reported on maternal health that, Black women in the United States experienced unacceptably poor maternal health outcomes, including disproportionately high rates of death related to pregnancy or childbirth. Both societal and health system factors contribute to high rates of poor health outcomes and maternal mortality for Black women, who are more likely to experience barriers to obtaining quality care and often face racial discrimination throughout their lives. Due to racism, sexism and other systemic barriers that have contributed to income inequality, Black women are typically paid just 63 cents for every dollar paid to white, non-Hispanic men. Median wages for Black women in the United States are $36, 227 per year, which is $21,698 less than the median wages for white, non-Hispanic men. These lost wages mean Black women and their families have less money to support themselves and their families, and may have to choose between essential resources like housing, childcare, food and health care. Erasmus (2017) carried out a research on the barriers to access for maternal health care among pregnant adolescents and the results showed that Negative perceptions included expected mistreatment by nursing staff and expected long waiting times. Many participants also reported poor knowledge of maternal health care services, which was a barrier to access to maternal health care services. 44 Akaliagung (2015) noted that key challenges inhibiting success in accessing maternal health services in Ghana were staff turnover, inadequate supervision, cultural practices and inadequate infrastructure. Barriers cited by Edu et al (2017) were poor knowledge of service, economic barriers (indirect cost and transportation cost), geographical barrier, drug stock outs, poor referral system, no means of transportation during labour, religious and cultural beliefs, women‘s low status in the society, poor quality of service, poor planning, monitoring and sustainability of programs. Poverty, low education levels, cultural practices and women‘s lack of decision making power significantly contributed to limited access and non-utilization of skilled maternal services which aggravates the effect of direct causes (WHO, 2012). However, maternal deaths are preventable provided that the pregnant women effectively utilize skilled healthcare services during pregnancy, childbirth and postnatal period (Chou et al, 2012 in Silali and Owino, 2016). Ogunmodede et al (2013) noted that ignorance, illiteracy, lack of health centres, power supply, attitude and perception towards information providers and language were found to be the major bottlenecks in the course of looking, accessing and utilizing sources of maternity information. Naanyu et al (2013) in a study on maternity relation information on mothers who were living in the western Kenya reported that women use church, public media and health care providers as their major sources of information for family planning issues. In conclusion, the researcher found a gap in literature that identified experiences of primigravida and how they access information on maternal health care services in Fatima community. The researcher didn‘t come across any literature that found that primigravida can‘t openly say they are pregnant because it‘s the first pregnancy, they believe a missed period can be translated to pregnancy but don‘t believe any intervention can prevent 45 mortality also grudges and rivalry can prevent a woman from accessing maternal health information.

2.2 Theoretical framework

The Pathway of Survival Model Theory by Mosley and Chen (1984).

This study is based on the pathway of survival model. According to Lopez (2000), this paradigm was first given by Mosley and Chen in 1984 and recently adopted by the World Bank as life cycle approach. The model depicts the interaction between the health system, the home and the community, in terms of motherhood and childcare. Mosley - Chen Framework consequently encompasses both social and biological elements connected to mother and child health care. It hypothesized that all impacts on mortality at the individual, household and community levels operate a set of common mechanism such as maternity factors, environmental and social variables in health care delivery.

Lopez (2000) pointed out that the pathway of survival is a guide that distinguishes between preventive behaviors such as immunization that require more direct effort from the health care system. He pointed out that this pathway shows how the management of illness can also be carried out at home in many instances with the mother being responsible for taking critical decision of when external help and support are required. World Bank in adopting the model included the more distal role of government policies and actions and so the revised framework includes health system interventions as well as promotion of appropriate household and community behavior as essential immediate steps between policy and out come Diamond (2002). It recognizes that integrated management of pregnancy, child hood, control of communicable and non - communicable diseases contribute one set of influence on household behaviors yet policies that determine the availability of health care supporting, food and sanitation and other related amenities such as water supply are equally important. This model recognizes that what happens in the household and the communities are most proximate determinant of utilization of available information communication and technology by mothers in accessing maternal and child health information.

Pender’s Health Promotion Model

The health promotion model is a framework for integrating nursing and behavioral science perspectives on factors influencing health behaviors which was developed by Pender et al. (2011). The health promotion model guides for exploration of the complex bio-psychosocial processes that motivate individuals to engage in behaviors directed toward the enhancement of health (Pender et al., 2011). The model describes that there are ten determinants of behavior organized into three major components which included:

i) Individual characteristics and experiences,

ii) Behavior specific cognitions and affect, and

(iii) Behavioral outcome (Pender et al., 2011).

Individual characteristics and experiences include the persons’ unique characteristics and experiences that affect subsequent action. The individual characteristics and experiences are divided into prior related behavior and personal factors. Prior related behavior which is the best predictor of behavior is the frequency of the same or a similar behavior in the past. Prior behavior is proposed as having both direct and indirect effects on the likelihood of engaging in health promoting behaviors. The direct effect of the past behavior on current behavior may be due to habit formation. The indirect effect can influence health promoting behaviors through perceptions of benefits, barriers, self-efficacy and activity related affect such as positive behavior, engendering high levels of efficacy and positive affect through successful performance of experience and positive feedback. Personal factors are categorized as biologic, psychological and sociocultural characteristics. These factors which are predictive of given behavior are shaped by the nature of the target behavior being considered. Behavior specific cognitions and affect include perceived benefits of action, perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal influences and situational influences. Perceived benefits of action can improve health behavior by motivating behavior directly as well as indirectly (Pender et al., 2011). Perceived barriers to action usually arouse motives of avoidance in relation to a given behavior. Perceived barriers to action affect health promoting behaviors directly by impeding action, and indirectly through decreasing commitment to a plan of action. Perceived self-efficacy is a judgment of one’s abilities to accomplish a certain level of performance, whereas an outcome expectation is a judgment of the likely consequences (e.g. benefits, costs). Self-efficacy motivates health promoting behavior directly by efficacy expectations and indirectly by affecting perceived barriers and level of commitment or persistence in pursuing a plan of action (Pender et al., 2011). Activity-related affect describes subjective positive or negative feelings that occur before, during and following behavior based on the stimulusproperties of the behavior itself. Activity-related affect influences perceived self-efficacy, which means the more positive the subjective feeling, the greater is the feeling of efficacy. In turn, increased feelings of efficacy can generate further positive affect. Interpersonal influences are cognitions of the behavior, believes, or attitudes of others. It includes norms, social support and modeling. These three interpersonal processes result in individuals’ predisposition to engage in health promoting behaviors. It also influences as determinants of health promoting behavior including moderate support for the construct. Situational influences are personal perceptions and cognitions of any given situation or context that can facilitate or impede behavior. They include perceptions of available options, demand characteristics, and aesthetic features of the environment in which health promoting behavior is proposed to take place and situational influences may have direct or indirect influences on health behavior (Sakraida, 2010). hence, this study is applicable to the information communication and technology by mothers in accessing Maternal and Child Health information.