Background: Everywhere in the world, Pregnancy and birth possess a risk to the life and health of women and newborns, regardless of whether a pregnancy was intended or unintended. The level of risk depends on a woman’s health before she is pregnant, her living conditions and the care she receives during delivery which is aggravated by lack of access to maternal health care services, leading to increase in the magnitude of death from preventable health problems. This paper therefore diagnostically assessed health promotion strategies for increasing access to maternal healthcare services in some remote districts in Anambra state. Methods: The study is a cross-sectional study and utilized a structured instrument which was validated by three experts in measurement and evaluation and health education and pilot tested on 20 pregnant women using test-retest in Ugwunagbor Abia state. The reliability yielded 0.84. Percentage, mean and standard deviation were used to answer the research questions. The population was 620 confirmed pregnant women from 4 to 9 months in the area of study in health centers in the state. A sample of 60 participants was selected using simple random sampling technique. Results: Findings show that antepartum, Intra-natal care, puerperium and family planning cares were prevalent in the local governments under study and that access to skilled delivery was associated with age, educational background, number of children and income level of the mother among other findings. Recommendations and conclusion: The researchers therefore recommended that there is urgent need to build healthy public policy, create supportive environments amongst others which can add to the effective measures of reducing maternal mortality in the longer term.

Maternal health is of great concern to all countries, especially in developing countries. It is not women’s issue alone; it is about the development and integrity of nations, societies and communities. Improving women’s health during pregnancy and childbirth has continued to be a global priority. Improved maternal health is a pre-requisite for women’s advancement, health promotion and national development. Yet low access and utilization of maternal healthcare of women, especially those in rural communities remain vulnerable and underserved. This adversely affects their production power and economic growth at large. Maternal health encompasses the health care dimensions of family planning, preconception, prenatal (antepartum), and postnatal (puerperium) care in order to ensure a positive and fulfilling experience, in most cases, and reduce maternal morbidity and mortality, in other cases [1]. Maternal healthcare is comprehensive as it includes educational, social, nutritional services as well as medical care during and posts pregnancy [2]. Women are also fundamental to the health, growth and quality of life of the nation. According to World Health Organization [1], mothers are the main providers of care and the role of women in nation development cannot be overemphasized; so ensuring the mother's health is a way to ensure the health and well-being of the entire family and the nation at large.

Access to maternal health care service has been an apt intervention to decrease maternal morbidity and mortality. However, Women and their health have largely been influenced by the African traditional culture and their location. Owing to the patriarchal nature of most of these African societies, diverse inequities are being perpetrated against women. It is not just what is done to women, but what is not done for them [3]. Furthermore, with peculiarity to the African societies, maternal health would include the ability to exercise reproductive rights of family planning and access to basic focused antenatal and postnatal care, without the encumbrances of patriarchal, financial or geographical inhibitions impacting on women’s health. Currently, Nigeria is the highest contributor to maternal mortality in Central and Western Africa and contributes 14% to the global maternal mortality rate. According to UNICEF [4], a woman’s chance of dying from pregnancy and childbirth in Nigeria is 1 in 13, and in 2015, mortality ratio for Nigeria was 814 deaths per 100,000 live births. Though a joint report by United Nations Children Fund, WHO, United Nation Population, United Nation Population Fund and World Bank [1] revealed a staggering decrease in maternal deaths in Nigeria between 451,000 in 2000 and 295,000 in 2017. Approximately 830 women die every day from preventable causes related to pregnancy and childbirth. And for every woman who dies, approximately 20 others suffer serious injuries, infections or disabilities. These happenings in recent time have great detrimental effects on the development of the nation. More worrisome is the fact that 99% of all maternal deaths occur in developing countries [5, 1]. Maternal death rate is a social indicator used to measure the development of any country, and the situation in Nigeria is of great concern. They further noted that Nigeria is ranked second after India in global maternal incident rate and the worst in Africa. The prevalence of maternal mortality in Nigeria has become very disturbing as every birth procedure becomes a potential incidence. Elem and Nyeche, [6] opined that this challenge may be connected to the poor access to maternal health care services mostly in the rural communities of Nigeria. Identification and application of appropriate health promotion strategies as an improvement package(s) for increasing uptake of qualitative maternal health services becomes vital. Health promotion strategies enable individuals and communities to increase control over their health and its determinants and thereby improve their health. It is a science and art of helping people, changing lifestyle to move toward a balance of physical, emotional, intellectual, social and spiritual health [7, 8]. These are strategies set out in the Ottawa Chatter for health promotion as essentials for success in any health promotion programs, with accessibility to comprehensive reproductive health services and health promotion packages women are less likely to die in pregnancy, more likely to have healthier children and better able to balance their family and work life [9]. Against this background, this paper assessed health promotion strategies for increasing access of maternal health care services in Nigeria.

The plight of women in Nigeria has vastly impinged on the achievement of developmental plans of the nation. Despite successive efforts to improve maternal health outcome in Nigeria, relevant indicators in the country had remained generally poor. A woman’s chance of dying during pregnancy and childbirth in Nigeria is high, at 1 in 13 (Compared to 1 in 31 for Sub Saharan African). Pregnancy and the period surrounding it remain dangerously insecure times for the approximately 9.2 million Nigeria woman and girls who become pregnant annually [10]. Nigeria is currently the second largest contributor to maternal mortality worldwide. Each day; about 109 Nigeria women die in childbirth, which approximates to one death every 13 minutes. Currently, Nigeria ranks among the bottom five out of 191 countries with the poorest –performing maternal health service delivery systems globally and second largest contributor to maternal mortality worldwide [11]. More so, in 2015, Nigeria’s estimated maternal mortality ratio became over 814 maternal deaths per 100 000 live births, with approximately 58 000 maternal deaths during that year. By comparison, the total number of maternal deaths in 2015 in the 46 most developed countries was 1700, resulting in a maternal mortality ratio of 12 maternal deaths per 100 000 live births. In fact, a Nigerian woman has a 1 in 22 lifetime risk of dying during pregnancy, childbirth or postpartum/post-abortion; whereas in the most developed countries, the lifetime risk is 1 in 4900. The country’s estimated annual 40,000 pregnancy related deaths account for about 14% of the global total deaths placing it among the top10 most dangerous countries in the world for a woman to give birth [12]. This situation calls for urgent need to improve women’s maternal health status in Nigeria. The problem of this study therefore is to assess the health promotion strategies needed for increased access of maternal health care services among Nigeria women. Identify health promotional strategies for increasing access of maternal health care services prevalent among women in Anambra, assess extent of access of maternal health care amongst women in Anambra state and identify factors affecting maternal health service delivery in Anambra state. The following research questions guided the study: What are the health promotional strategies for increasing access of maternal health care services prevalent among women in Anambra ? What is the extent of access of maternal health care amongst women in Anambra given by trained health workers? What are the factors affecting access of maternal health care services in Anambra state?

An analytical cross-sectional study was conducted from August to November 2018 in the health centres in Idemili north of Anambra state. The centres were one of the most deprived health centres in the Anambra state and uniformly rural. It had a population of 620 attendants and an annual growth rate of 2.7% as of 2018. The health system in the local government is very weak, low doctor, health staff-to-patients and midwife to women in reproductive age (WIRA) ratios. The study population was defined as confirmed pregnant women from 4 to 9 months. Sixty (60) pregnant women were systematically sampled from 3 towns in the local government from the various anti-natal clinics (ANCs).

All participants involved in the study signed an informed consent form after explaining the objectives of the study. Participants had the right to withdraw from the study at any point in time during the data collection process. Data on respondents’ socioeconomic characteristics, access to maternal health care services were collected using structured questionnaire which was validated by three experts in measurement and evaluation and health education checking for clarity, consistency, and acceptability by pretesting. The structured instrument was pilot tested on 20 pregnant women in Ugwunagbor Abia state using test-retest reliability technique. This yielded reliability estimate of 0.84. Percentage, mean and standard deviation were used to answer the research questions. Data entry and analysis were done with SPSS for Windows (version 22)

Research Question 1: What are the health promotional strategies for increasing access of maternal health care services prevalent among women in Anambra state?

Table 1 showed the proportion of access to health promotional cares. This showcased that antepartum care with a ratio of 0.75 (75%) were most received by pregnant women in Idemili north local government area, followed by intra natal care 63%. The rate of giving puerperium and family planning care were low, at 48% and 23% respectively.

Research Question 2: What is the extent of access of maternal health care amongst women in Anambra given by healthcare workers?

The results on table 2 indicated that most women (65%) had three or more antenatal visits during their previous pregnancies whereas 6.7% had none, about 68.3% had puerperium care within three or more. About 13.3% received no toxoid vaccines during previous pregnancies whereas 21.7 and 30% received one and two respectively. 35% of respondents received a day of puerperium care by a trained health care worker (HCW) whereas 20.6% were visited three days or more during puerperium by trained HCW.

Research Question 3: What are the factors affecting access of maternal health care services?

Evident in table 3, access to skilled delivery was associated with age, educational background, number of children and income level of the mother. Older mothers (> 34 years) had higher odds of skilled delivery compared to younger mothers (< 24 years) (OR; 95% CI: 2.7; 1.13, 6.59). Having some form of education was also associated with skilled delivery as compared to no form of education. However, in contrast with access to ANC, having more children was associated with lower odds of having skilled delivery. Use of health facility as the main source of healthcare was also associated with higher odds of having skilled delivery (OR; 95% CI: 2.3; 1.49–3.73). Compared to the lowest wealth quartile, being in the highest wealth quartile was associated with higher odds of receiving postnatal care (OR; 95%CI: 2.66; 1.63, 4.94).

The following were identified by the participants to be the most popular maternal health care promotional strategies prevalent in the health care centres in Idemili north local government in order of provision. They include

Antepartum care: A greater proportion of participants 74.8% (p=0.75) reported that they recieved antepartum care greatly throughout their pregnancy period. Though regretable through more of non-governmental sponsorship. This is in agreement to the report of some health scholars who opined that antepartum care is the advise, supervison and attention a pregnant woman receives to ensure good health throughtout the period up to having a live healthy baby at the end of pregnancy. This is truely the plannned examination observation and guidance of an expectant mother [13, 14]. One of the goals of the service is to care for all pregnant mothers and to have all births attended to by the trained health workers, to identify pregnancies where risk is high and provide special care for the mother and the infant. In the course of this investigation, the researchers found out that antepartum care section helps to identify the danger signs or predicts complications around delivery by screening for risk factors and arranging for appropriate delivery care when indicated. Antenatal services screens for and treat disorders such as anaemia, hypertension, diabetes, syphilis, tuberculosis and malaria, as well as check the baby’s position in addition to counseling on such matters as diet, hygiene, the danger signals in pregnancy and breastfeeding. This is a very essential aspect of maternal health care. Though United Nations Children Fund [15] emphasized that it is also important, however, not to overburden antenatal services to the point at which they become overstretched.

Intrapatum care: this is another important maternal health care promotional strategy as identified by participant in this study. This care begins with the onset of labour and after delivery which includes the examination of mother and baby to confirm that both are in good condition. This was identified by the 62.6% (p = 0.63) of the participants as the second most assessed health care service given during pregnancy. This implies that a good portion of pregnant women in the rural communities receive this care but the fear remains whether it is from a trained health worker (doctor, nurse or midwife) or not. This is in line with Aluko-Arowolo and Ademiluyi [2] who reported that this service is crucial and includes thorough asepsis , delivery with minimum injury to infant and mother , readiness to deal with complications (prolonged labour, convulsion, mis-presentation, prolapsed of cord , etc) and care of the baby at delivery (resuscitation, care of cord , eyes, etc).

Puerperium care: this was identified by 48% (p=0.48) of the subjects as being given in the centres, which indicated that a greater part of the mothers of child bearing age were not given adequate attention after delivery. This affirms the report of Adetoro [16] and Tabassum [14] who said that this intervention has long been neglected in many developing countries and one that represents a gap in the continuum of care. Routine puerperium visits are necessary in the high-risk post-partum period, when any complications need to be promptly detected and referred to more expert services if required. Even in the absence of complications, these visits can provide essential information and guidance on maternal and newborn health – especially on the care and feeding of babies, the danger signs of illness, referral processes or referral for treatment of mother or baby. Post natal care services are mostly incorrectly given, least attended to and usually neglected [17]. Despite the importance of this care system, research has shown that most mothers in developing country as Nigeria sought alternative healthcare before presenting at their preferred source of healthcare. Some of the pregnant women purchased medicines from the chemist while others sought healthcare from other sources. A study in a rural western community of Kenya, also found that a third (32.4%) of mothers purchased and administered drugs to their sick children without seeking medical attention. Similarly, a study in the slums of Nairobi, Kenya found that most mothers resort to chemical shops as their first source of healthcare, and when the care moves out of the home, private health facilities are used more compared to public health facilities [13]. This could result in late presentation at the health facility resulting in complications and deaths.

Family planning services: Only 23% of mothers indicated knowledge of the care. Family planning was identified as a means of promoting the health of women and families and part of a strategy to reduce the high maternal mortality rate, infant mortality rate and child mortality rate; preventing maternal mortality by reducing exposure to pregnancy and therefore to risks associated with pregnancy and childbirth in the event of wanted births. This service according to the participants is not cared about by many mothers.

Extent of access of Maternal Health Care Services in Nigeria: The findings of the study revealed that a greater percentage of women from middle to lower economic status does not benefit from the maternal health care services provided by even government body. It was observed from literature that such women depend mainly on philanthropy. This was due to the fact these philanthropy and/or NGO’s trace such women to their remote abodes to render such services. Nuamah [13], in their report affirmed that the uptake of maternal health care services is influenced by socio-economic characteristics of pregnant mothers. This suggests the need for tailored intervention to improve maternal healthcare utilization for mothers in rural and other similar settings.

Factors affecting access of Maternal Health Care Services in Nigeria: The participants of this study identified so many factors that affect their access of Maternal Health Care Services as follows:

• Socioeconomic factors which include: gender discrimination, economic status, education and age -early age at menarche, early age at first birth, low parity and frequent birth intervals associated with increased risk of maternal mortality, for instance, in maternal age, where age 10-14years has five times higher risk than age 20-24 years. In many parts of Nigeria and Africa at large, women must seek permission from their husband or family to visit a clinic for care. Even when permission is given, women’s lack of autonomy in their families still prevents them from seeking care. In line with this, Women Deliver [18] reported that other family members may consider childbirth as a woman’s concern and not that of the household. As a result, woman may find difficult to get the money to pay for services or to obtain transport to get to medical center. More so, lack of education for women prevents them from making informed decisions about their health and sometimes from knowing when to seek care. Adetoro [16], also agreed that cultural practices such as polygamous marriage, extended family practice, male child syndrome, celebration after the birth of the tenth child, which encourages competition for more children over stretched resources and deprivation, traditional food taboos, cultural beliefs such that a woman in labour must endure suffering (just like in the Northern part of Nigeria.
• Access to healthcare service factors such as high cost of maternity services due to user fees for health services provided and professional healthcare are too expensive for many women. This high cost could be fees for the use of facilities, services and drugs. Most of the fees are outrageous and when combined with the cost of transportation to clinics and the possibility of lost wages from work, they are not just limited but highly prohibited [19]. Access to quality maternity services becomes a primary obstacle basically when they need it most which is compounded by inadequate trained personnel, lack of essential supplies of drugs and basic instruments for treatment. Africa faces a health-worker crisis: on average, there are only 13.8 nursing and midwifery personnel for every 10,000 people [9]. Proximity to health facilities poses a great challenge. Poor road infrastructure and poor transportation present hurdle to effective care especially in rural areas; clinics are often too far away or otherwise inaccessible. Frequently, there are no roads to the nearest health facility or existing roads are impassable due to road quality, terrain, natural disasters or the rainy season. This can be particularly dangerous for women suffering from obstetric complications, where delays in reaching medical care can have permanent consequences [20].
• Knowledge (Information Deficit): Most governments in Africa face a lack of accurate data on maternal health and existing funding. This affects accurate funds allocation on how much is needed and what programmes are most effective. The lack of accurate, up-to-date statistics on maternal deaths prevents governments from allocating resources most efficiently to maternal health issues. According to World Health Organization [1], globally there are unregistered deaths of 40 million people while other 40 million persons are born without record each year. Attitudinal defects of health workers of maternal patients in many areas frequently stop women from accessing existing healthcare resources – maternal or others. There are aversions to surgical deliveries, unfriendly and uncompassionate attitude of health workers during pregnancies and after childbirth that creates a social and psychological distance between maternal population and the health institution limiting accessibility [1].

Diagnostically, health promotion is clearly a process directed towards enabling people to become active in shaping their own health (develop personal skills), thus, exerting control over the determinants of health and for positive change, by, with, and for people as individuals or groups. To be able to take such an active role, people and groups need to be empowered. And when the empowerment becomes effective at the level of the individual, the person shall become health literate, meaning that a person/community has the skills to access, understand, and use information for health [1]. Based on the findings of this study therefore, the researchers recommended as follows:

• Building of healthy public policy: Building healthy public policy as a health promotion strategy goes beyond health care. It puts health on the agenda of policymakers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. This joint action would contribute to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments.
• Creating a supportive environment for maternal health: This will challenge the social, economic and cultural barriers that perpetuate gender inequality and discrimination. This will also involve several key actions: educating girls and women, and reducing the poverty they experience; protecting girls and women from abuse, exploitation, discrimination and violence; fostering their participation and their involvement in household decision making and economic and political life; and empowering them to claim their rights and essential services for themselves and their children. It will entails greater involvement of men in maternal and health care and in addressing gender discrimination and inequalities which is also critical to establishing a supportive environment.
• Reorienting health services: Reorienting health services move increasingly the role of the health sector in a health promotion direction, beyond its responsibility for providing clinical and curative services, directing health services on the need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services, which refocuses on the total needs of the individual as a whole person.
• Access to quality health services by women is vital for reduction of maternal mortality. Health institutions should be refurbished and have up-to-date facilities. A working health system which includes provision of right drugs, adequate supplies, equipment and functioning facilities improves maternal health through reduction in numbers of higher risk pregnancies, lowering inter-pregnancy interval and reduction of preventable deaths. Medical professionals should be mobilized and retained in rural communities for the populace to access these good services and extend them to women during pregnancy and after child birth.
• Available Trained Health Workers i.e. well trained health workers, paid duly supervised and supported by a health system which can quickly provide obstetric care in emergencies.
• Reduction of user costs through free care, subsidies and vouchers and payment exemptions or eliminating fees at primary health centers which will encourage women to seek medical care rather than attempt in-home delivery or unsafe abortions. Addressing delays in receiving care in Nigeria, some organizations have begun partnering with local communities to improve their emergency transport systems to hospitals. These programmes should be expanded and should target high-risk communities in the remote -rural areas of Nigeria.
• Provision of means of communication to health personnel can improve access for those in need of care. Phones allow pregnant women to ask questions of health workers and alert them when they are going to labour. Conversely, it allows the health workers to communicate data to health facilities.
• Education for all women is a panacea to high rate of maternal mortality among women. Investing in girls and women, particularly in education for girls, can be an effective measure to reduce maternal mortality in the longer term. Educated girls tend to marry latter and have fewer and healthier and better-nourished children. Mothers with little or no education are less likely to receive skilled support during pregnancy and childbirth [21, 22].

Health promotion strategies encompasses a wide range of approaches that are united by the same goal, to enable people to increase control over and improve their health it is all about raising the health status of individuals and communities. It is a concept which is of high relevance to resource of poor communities as it uses a very holistic development approach and addresses many of the social, environmental, cultural systems related aspects of the determinants of health, empowering all at the heart of this agenda. To increase access to Health Promotion strategies, several action areas were recommended such as building Healthy Public Policy, Creating Supportive Environments and Re-orienting Health Services as ways of tackling maternal health services, maternal health problems, and motivating increasing uptake of maternal health services by women. Maternal mortality data is said to be an important indicator of overall health system quality because pregnant women survive in sanitary, safe, well-staffed and stocked facilities. If new mothers are thriving, it indicates that the health care system is doing its job. If not, problems likely exist.