Reflection is an act of training that is adaptable or a method which encourages independent knowledge that points to progress learners mind and analytical thinking abilities. It aims to link the space amongst model and exercise, express the interaction of services, information and the context of health care ( Mamede, et al., 2012).

As a student, it is good to have a bright reflection to balance what’s actually going on around; at times it might require lots of recollecting and time. Some many aims are called for reflecting on procedure, like improving practice healthy, making others understand that their thoughts or doing are not effective as it ought to be given satisfaction. The reflection could also be an experience where one can recall knowledge and think how to assess it to solve a solution. The importance of reflection in many professions such as nursing, doctors and teaching has helped the profession services to improve their level of skills for future functioning by assessing the state, level of errors that has occurred previously and find a better solution to it against the future. It has given stronger thoughts around the caring of a lifetime and work they desire, better assurance in the selections they desire. It has created better self-confidence in the services, potentials and qualities they produce for the profession of their choice. It has also made professional life remaining in a progress side to contest for occupations as well as giving the sense and abilities to examine their skills, private abilities and capabilities with managers. Finally it has help in good problem-solving and design services.

Reflection is the heart of effective learning to the development of all professionals simply because it allows everyone to learn from practice. Reflective practice has different methods of dealing with issues such as self and peer assessment, problem-based knowledge; personal development planning and assembly work can altogether be expanded to back a reflective methodology.

In discussing how reflective practice can be used in professional body to ensure continuing professional development. When the concept of reflective practice was initiated by Donald Schön (1983) schools, colleges and every education area started planning educator teaching and professional development plans centered on this idea. The significance of reflective in educational module is to ensure more planning and it will expose a choice of styles. It will identify different way in which team partners select to reflect on specific actions. Action study is an instrument of program training containing of continuous response that aims particular problems in a specific group setting (Hopkins & Antes, 1990). By means of this, it develops a standard idea in teacher learning curriculums. The trainer mentor as academic and role example inspires students to place philosophies they’ve studied into practice in their schoolrooms.

Involving myself in a professional development institutions is a way to combine reflection into practice. The reflective medical health method has been introduced in some occupation area and it has developed into the work series in one way to the other, all the way through appraisals or assessment. Normally, it’s a ways of accepting personal accountability for issues like:

Their continuous practiced development (CPD).

Creating a reasonable and sensible assessment of their personal work.

Distinguishing their personal powers and anywhere they want to make a values influence to a team or workforce.

Knowing their personal limits and recognizing the education they want to advance my working.

Be aware of their own performance with others and accepting accountability for their activities.

The ability to know when they should make a valuable impacts to a group dialogs and when not and seeing ways of educating individual also team functioning.

The question about reflective practice is how does it delivery and improve quality care when change is introduced with a service or management or how can one understand if these changes benefit the service users. Everyday group and monitoring of client information can be a good practice for this. The procedure of measuring and evaluating the benefit can be signified to as the performance pointers subject to what is about to be measured. Some of the tools used to measure the results of therapy can support organization to see the importance of incoming information if this data are exercised to recover client care. This information needs to be interpreted into significant evidence that could notify choice creation at home and organization level if they are going to implement good practice.

Performance pointers are goals set by a team, sector or service, at time it may be detailed to success of standards, lessening the time of waiting or client release. The performance pointers can be amended over time and reflect the development of correction in a team and this has been witnessed in the change of models used in different sectors. Being reflective in a team, it will help to prove that health worker, professionals are vigorously worried around the goals and penalties of the labour they are responsible for, allows all individuals to screen, assess and study their own training constantly. It makes them to be observed sensibly at training, instruction to acquire new competencies and empathetic and the needs for unbiased approach. It also improves professional knowledge and individual satisfaction throughout teamwork and conversation between practitioners.

In a precise case of the nursing professions in a care home setting (Appendices 1.), it is advised that the professional to recognize, respect and perform actions that will protect the person’s right to make a decision about their health, cure, and well-being, turning them excused from any kind of unfairness (Gardiner, 2003). It also compels them to execute or contribute to health care without the approval of the patient, apart from in cases of looming risk of death (Volbrecht, 2002). Hence, any nursing intervention is required to be voted on the bioethics principles of malfeasance, non-malfeasance, beneficence, and autonomy and it can only be conducted with the permission of involving person, based on sufficient information (American Nurses Association, 2001).

Conclusion

The need for bathing in this case certainly has created an ethical dilemma to the care giver, because this procedure involves the collision of two fundamental rights: the basic right to health and the right of denial due to personal values or past experience. Caregivers know that force bathing is basically acting against the patients’ rights according to nursing guidelines and realization of the fact is also imperative that experience of force bathing will create even more complexities in the future care management of Mr. James. Although, bathing him very important for his health yet this situation requires health care giver professional to make a decision in favor of the pervasiveness of the dignity as the boundary and bottom for her other rights these dilemmas in the case of Mr. James can be solved by means of alternative counseling. Caregivers in such a situation require to make deepening understanding of Mr. James mental block and difficult behavior.

As a caregiver first task was to collect complete information about this difficult behavior of Mr. James from him and his family members, Mr. James was encouraged to speak of his previous bad experience; it requires patients to bear harshness and indecent language. After gathering the fact related to his behavior next step was to evaluate the situation which required the identification of problem, solution and alternative option. The caregiver decides to convince Mr. James to have a bath continuously. The strategy adopted was instead of making him bath care givers started to ask him on routine would he like to have a bath, the advantages of having a bath and disadvantages of not having were lightly and repeatedly presented to him. Being a care givers professional I decided that an ongoing attempt to persuade Mr. James to have a bath will keep going till he himself agree to have a bath but he will not be forced bath and his personal dignity will be kept supreme.

Appendices 1

MR. James was admitted in the care care Home where I am doing my placement suffering from memory loss. He was accompanied by family and was skeptical about my ability to give him bed bath as a result of some abuses he had received in the past and competency. However , after much talk and the senior carer appeal to him to allow me to give him bed bath that he will okay yet Mr. James was just behaving funny using swearing words and turns deaf ear. Some family of Mr. James member also joins to talk to him but he refuses.

The coverage of antenatal care (ANC) in many areas is known and there are a number of interventions to encourage use of ANC services by pregnant women. However, for women who attend ANC, it is important that they register at the appropriate time and pay a given number of visits over the pregnancy period to ensure that they receive the interventions recommended for the antenatal period at the right time. When a pregnant woman makes regular contact which her skilled antenatal care provider, she is in a position to receive various services such as those meant for prevention of eclampsia, intermittent preventive treatment for malaria, early detection of HIV/AIDS infection and prevention of mother-to-child transmission, micronutrient supplementation, birth preparedness and provision of information on danger signs occurring while she is pregnant or during delivery.1 Presently, Nigeria is transiting to the Focused Antenatal Care (FANC) approach promoted by the World Health Organization (WHO) which is aimed at ensuring that each antenatal visit counts and that antenatal care interventions are delivered at the appropriate time.2

FANC is one of the pillars of safe motherhood. The goal of FANC is to ensure that pregnancy is normal through for major actions: identification of pre-existing health conditions, early detection of complications arising during the pregnancy, health promotion and disease prevention and birth preparedness and complication readiness planning.3The interventions are deployed in such a way that they are appropriate for the woman’s stage of pregnancy.4 Unlike the previously used routine care which was ritualistic and frequent visits, the FANC approach emphasizes evidence-based goal-directed actions, family-centred care, quality, rather than quantity of visits as well as care by skilled providers.3 4 Thus, numerous routine visits are no longer recommended and are considered a burden to women and the health care system.

The FANC approach also deemphasizes the routine risk assessment approach for classifying women into high and low risks groups.2 With the risk assessment approach, women attending antenatal care were offered services which include blood pressure check, urinalysis to detect protein or bacteria, and blood test to rule out syphilis or anaemia.5 However many women classified as low risk end up having a false sense of security, are unable to recognize and respond to problems and end up developing complications. In addition, most high risk women give birth without complications and the excess care provided constitutes an inefficient use of scarce resources.

The FANC approach in Nigeria requires that pregnant women would have paid the first visit for ANC by the 16 week of pregnancy or earlier when the women first thinks she is pregnant, the second between the 24th to 28th week, the third at the 32nd week and the 4th at the 36th week of pregnancy.2 Some authors have considered early booking to mean that a woman pays her first visit before the 14th week to achieve the aim of improved outcome of pregnancy both for a mother and her unborn child.6 Thus, by 36 weeks, a pregnant woman should have made the required minimum of four visits while those with risk of complications of conditions that can impact on pregnancy would require additional visits.

The time of booking and ANC attendance can affect the effectiveness of interventions recommended for pregnant women and thus the goals of FANC. Early booking helps ensure that problems are detected and managed early.2 The first visit gives the opportunity to record information on family, maternal and medical history, carry out a physical examination, request laboratory tests, provide care including intermittent preventive treatment (IPT) for malaria in pregnancy (if beyond first trimester), provide counselling including birth plan, use of insecticide treated bed nets (ITN), HIV counselling and testing and to discuss the schedule for care. The subsequent visits are necessary for noting complaints, targeted physical examination, reviewing test results, providing care including IPT for malaria, obtaining information on use of ITN, birth plans and carrying out HIV counselling.

Justification for the study

Interventions for pregnant women aim protect the woman and her unborn baby for the remaining period of the pregnancy and their provision should be timely. The later the timing of first visit the shorter the period of cover and the higher the risk of development of problems and complications for the woman and her baby. Thus it is not just important to know the proportion of pregnant women attending ANC, it is also important to know when attendees commence such visits and whether they pay an adequate number of visits.

Although a number of studies have documented the timing of first visit and number of visits to ANC in the south-west region of Nigeria, little is known about the pattern in the south eastern region of the country. Additionally, most of the studies are limited in scope as they are facility based (usually tertiary hospital based) and thus reflect experience amongst pregnant women who are able to access such facilities even though primary health centres are the closest to people and usually the only available point of care in rural areas.

Aim: This study is aimed at documenting the socio-demographic predictors of timing of ANC booking and subsequent attendance amongst pregnant women in order to understand the impact these can have on deployment of focused antenatal care interventions for pregnant women.

Objectives:

To determine the timing of booking and pattern of subsequent ANC attendance among pregnant women attending primary level facilities

To examine whether the timing of ANC booking and clinic attendance is affected by individual level socio-demographic factors

To assess the appropriateness of timing of booking and attendance for effective delivery of focused antenatal care interventions

To examine how the findings of the study can impact on the deployment of antenatal care interventions for pregnant women.

CHAPTER TWO LITERATURE REVIEW

The concept of focused antenatal care is based on the assumption that since every pregnancy faces the risk of development of complications, every pregnant woman should be monitored to avoid development of such complications.2 Lack of antenatal care is known to be a major risk factor for development of negative pregnancy outcomes. However, when antenatal care is appropriately delivered, it has the potential to positively impact on maternal mortality and morbidity.7 Studies have shown that many women obtain care quite late during the pregnancy period and the care obtained is usually inadequate.2 8 9

The first visit for antenatal care in Africa usually takes place around the fourth to fifth month of pregnancy.5 In the African region, 73% of pregnant women aged 15 – 49 years pay at least one visit to a health care provider for antenatal care while only 44% pay at least four visits.10 A study by Al-Nasser in Saudi Arabia showed that majority (60.8%) of pregnant women attending antenatal clinic in primary health care centres were first seen before the 20th week of gestation.11 Fekede, et al noted that 42.8% of 360 pregnant women in an Ethiopian town attending antenatal clinic did so for the first time within the 3rd trimester while only 6.5% had the recommended minimum of four visits.12

In Nigeria, the figures assessing antenatal care utilization are below the African regional values as 58% of women aged 15-49 years receive ANC from a skilled health provider at least once during pregnancy while 45% of women make four or more visits for ANC.2 10 Based on the 2008 NDHS the median gestational age at booking is 5 months.2 Among 395 women attending antenatal clinic in public and private facilities covering the primary, secondary and tertiary levels of care in Ibadan, southwest Nigeria, 25.8% paid the first visit for antenatal care within the first trimester. Mean gestational age at booking was found to be 18.5 (±6.3) weeks while the mean number of antenatal visits was 4.0 (±2.4).13 A study carried out among 378 pregnant women attending a tertiary hospital in Edo state Nigeria noted that the 6th month of pregnancy as the peak period of first visit for antenatal care among the women.14 Okunlola et al found a mean gestational age at booking of 21.82 (±7.0) weeks with only 14.1% of the women paying attending for the first time within the first trimester.6 In a tertiary facility in Osogbo Nigeria, the mean gestational age was found to be 20.3 (±6.2) weeks and 82.6% of those studied booked late.15 Amongst 400 women attending antenatal clinic at a tertiary facility in Ile Ife, Nigeria, 71% had registered by the 20th week of gestation.16 Aluko and Oluwatosin found low rates of first trimester booking and irregular visits for antenatal care among women attending clinics in a mission hospital in Ibadan south west Nigeria.17

Socio-demographic factors and parity have been found to directly influence the timing of first visit for antenatal care though the results are sometimes dissimilar. Most women (79.9%) attending antenatal clinic in a tertiary hospital in Edo state Nigeria were found to have booked late.18 However, there was no significant difference in age, parity, level of education and social class between women booking early and late. In a study carried out among pregnant women attending a the Lagos University Teaching Hospital, Adegbola found a mean gestational age at first booking of 18.5 (±8.3), 18.4 (±7.4) weeks for nulliparous and primiparous women respectively.19 The overall mean gestational age at booking was 19.1(±7.2) weeks. Women with parity 5 booked at significantly higher mean gestational age of 25.9 (±) weeks and women of lower social class tend to book earlier for antenatal care. Similarly Adeyemi, et al found that late booking was thrice as common in multiparous women compared with the nulliparous group and the difference was significant.20 Other authors have found an association between parity and timing of first visit, and number of antenatal visits.11 21

A number of studies have documented the factors that affect use of ANC amongst women in the developing countries;9 these determinants are also likely to affect the timeliness of attendance for ANC. Chandrashekar, et al found that women who are poor, illiterate, multiparous, unskilled and over 30 years of age were less likely to receive antenatal care in India.22 Age was found to be a significant predictor of ANC attendance in a community based study in Ethiopia where women aged 15-24 years were found 2.75 times more likely to attend than those aged 25-34 years.12 Geographic place of residence can also have an impact as women living in urban areas are more likely to receive antenatal care during pregnancy.

Women have also been found to concurrently use multiple antenatal care providers and this can affect the timing of booking in a facility. Adeoye, et al found that 25% and 30.5% of women attending two antenatal care clinics in a tertiary facility in Ebonyi state were concurrently using both formal and informal providers of antenatal care.23 Of 535 women attending a tertiary facility in Enugu Nigeria, 69.5% were booked in more than one facility.24

The time of commencement of ANC visits has implications for the period of protection that pregnant women have from interventions. For example where women attend antenatal care late in pregnancy, they may not receive the recommended 2-3 doses of Intermittent Preventive Treatment (IPT) for malaria in pregnancy using sulphadoxine-pyrimethamine combinations.25 Data from the 2008 National Demographic and Health Survey (NDHS) shows that among 11,027 women aged 15 – 49 years with a live birth within a period of 2 years preceding the survey, only 8.0% received at least one dose of IPT while 4.9% received 2 or more doses.2 The proportion was 9.9% and 5.4% respectively for the south east region of Nigeria. It is important that pregnant women are available at the appropriate time for delivery of IPT which is best given when the growth of the foetus is occurring at its highest velocity (16th – 24th week) as this helps to reduce placental parasitaemia, foetal growth reduction and the resultant low birth weight.26

It is also known that the negative impact of malaria is worse among women with their first and second pregnancies compared to those that have had more than two pregnancies.27-29 Thus primi and secundi-gravidae need to pay their first visit early enough to ensure adequate protection through the pregnancy period. The same consideration holds sway for interventions such as insecticide treated nets for which the potential protective time period depends on how early in pregnancy a woman starts sleeping under the net.

All it all, timely attendance to ANC is important to enhance the potential for positive pregnancy outcomes since it provides pregnant women with the opportunity to receive recommended interventions and the protection from problems and complications. Socio-demographic and maternal factors such as parity can affect the timeliness of ANC visits by pregnant women.

CHAPTER THREE METHODOLOGY

Study area: This study will be carried out in Enugu State, South-East Nigeria. Enugu state comprises of 17 Local Government Areas (LGAs), has a total population of 3,257,298 people and an annual growth rate of 3.0.30 Three of the 17 LGAs (Enugu North, Enugu South and Nsukka) are urban, one (Enugu East) has a mix of urban and rural areas while the remaining 13 LGAs are rural. The people of Enugu are of Igbo ethnicity and are predominantly Christians. A substantial proportion of the working population in the state is engaged in farming, trading, and public service employment.

Study site: Two areas will be purposively selected for the study to enable collection of data across for those in both urban and rural areas of the state. These are Udi LGA comprising Udi North and South Development Councils will be used to represent the rural areas while Enugu North and South LGAs will represent the urban areas. Udi has a population of 234,002 while Enugu North and South have a population of 244,852 and 198,723 respectively.30 Udi LGA has 14 primary health facilities that offer ANC services while Enugu North and South (referred to as Enugu) together have 12 primary facilities that offer ANC (appendix 1).

Study design: This will be a cross-sectional study involving eliciting of information from pregnant women attending primary health centres for antenatal care through exit interviews using a pre-tested questionnaire.

Sampling and sample size: All the primary health care facilities providing ANC in the study LGA’s will be used for the study. Since the level of attendance of ANC varies for different facilities, a proportionate method will be used for determining the sample size for each facility. The proportion will be determined by considering the average weekly number of antenatal clinic attendees to the facility relative to the total from all facilities as reported by the heads of the facilities and the relative proportion will be computed.

The minimum sample size required for the study is 374. This was determined using the formula for determination of sample size for population proportion,31 an ANC coverage level of 58%,2 a confidence level of 95% and an error margin of 0.05.

Z= 1.96 at 95% confidence level, (two-sided).

p=ANC coverage = 58%

d=margin of error tolerated = 0.05

Considering a potential refusal rate of 10%, 411 women will be sampled.

Study tools: Data will be collected using a pre-tested interviewer administered questionnaire (appendix 2) which will be administered by trained field workers. The questionnaire will be pre-tested amongst pregnant women attending ANC at the Primary Health Centre Abakpa, Enugu East LGA which will not be used for the study.

Data analysis: Epi Info statistical software will be used for data entry while SPSS and Stata Softwares will be used for data analysis. Data will initially aim to elicit the determinants of timing of booking of ANC. Subsequently, a continuous socio-economic status index will be generated using the principal component analysis technique in STATA software package 32 to enable disaggregation of data into socio-economic quintiles. Information that will be used include households’ asset holdings including television, radio, refrigerator, car, bicycle, rechargeable lamp, kerosene lamp, electric fan, air conditioner, motorcycle.33 The SES quintiles generated will be used in assessing differences in timing of booking for women of various SES groups. Logistic regression analysis will be employed for examination of the determinants of the timing of booking. Data analysis will also aim to estimate the proportion of women attending at the appropriate time for delivery of recommended interventions. Chi squared test will be used to test for significance of differences observed for categorical data while chi squared for trend test will be employed for ordered categorical data. All tests of significance will be done a p value of 0.05.

Ethical considerations: Ethical clearance will be obtained from the Research Ethics Committee of the University of Nigeria Teaching Hospital Enugu, while permission to carry out the study will be obtained from the Primary Health Care Coordinator of the LGA’s as well as from the heads of facilities to be used. Written consent will be obtained from patients who are interviewed after they have been informed of the objectives of the study and the voluntary nature of their participation.