Factors That Influence The Utilization Of Antenatal Care Services In Selected Public Hospital In Ilorin West Local Government Area, Kwara State, Nigeria
1.1 Background to the study
Improving maternal health is one of the World Health Organization (WHO) Millennium Development Goals (MDGs) and professional health care during child birth is one of the process indicators in assessing progress towards these goals. WHO has recommended four strategic interventions or four pillars for safe motherhood. These include; Family planning, Antenatal care (ANC), Clean/ safe delivery and Emergency obstetric care. Some of the interventions that have been shown to be effective in detecting, treating or preventing conditions in pregnant women that might otherwise give rise to serious morbidity and mortality are: detection and investigation of anaemia, pregnancy induced hypertension, treatment of severe pre-eclampsia, screening and prevention of infection and diagnosis of obstructed labour. For all the benefits that have been attributable to ANC, the effectiveness of antenatal care in actually reducing maternal and fatal morbidity and mortality, has never been scientifically proven and because of ethical considerations may never be proven. Utilization of ANC services has been identified in a number of studies as an important factor determining maternal and infant mortality. However, the use of health services is a complex behavioral phenomenon. It is affected by socio-demographic factors (such as age, occupation, education, and marital status, religion and income level.), accessibility of the health facility, knowledge about antenatal care services and the quality of care services provided at the health facility. In a study on the determinants of maternal health services in the rural India, it was found that, there is a correlation between household income and utilization of maternal health services . It was evident that as a result of lack of productive resources for women, income earned by women had negative impact on utilization of ANC and Post Natal Care (PNC).
Lack of knowledge about the ANC services could be a major barrier to women’s utilization of ANC services. Due to lack of knowledge pregnant women are likely to have limited knowledge and experiences in seeking health care. Matua cited lack of adequate knowledge and information about pregnancy, laboratory tests results and dangers of late bookings or not attending ANC at all, as contributors to the poor utilization of ANC services. Lack of knowledge about the dangers of not seeking health care in pregnancy and delivery were major barriers to seeking health care among pregnant women in Uganda. It is evident from previous researches that, the knowledge about the antenatal care services, availability and accessibility of the services, the distance to the facility, the efficiency and skills of the staff/ workers hence quality of the services, costs incurred, that is the screening charges, transport costs, and the treatment costs, continuity and comprehensiveness of services, all play a part in influencing the utilization of antenatal care services. This however did not tell us to what extents these factors influence the utilization of ANC services. Furthermore, it is also affected by cultural beliefs, as well as personal characteristics of the user of these services. Sometimes the government policy too may affect ANC utilization.
Nigerian Health Review, reports that one of the major causes of maternal deaths is inadequate motherhood services such as antennal care. Approximately two-thirds of all Nigerian women and three-quarters of rural Nigerian women deliver outside of health facilities and without medically-skilled attendants present. Data from the Nigerian Demographic and Health Surveys indicated that among pregnant Nigerian women, only about 64% receive antenatal care from a qualified health care provider. There are wide regional variations, with only about 28% of women in the Northwest Zone and 54% in the Northeast Zone receiving antenatal care from trained health providers (NHR. The rest either do not receive antenatal care at all or receive care from untrained traditional birth attendants, herbalists, or religious diviners.
There are studies in Nigeria that have related maternal health to care utilization and other risk factors. For example, Ibehstudied maternal mortality index in Nigeria in relation to care utilization using Anambra state as case study and attributes high maternal mortality to poor socioeconomic development, weak health care system, low socioeconomic status of women, and socio-cultural barriers to care utilization. He found that about 99.7 percent of women in the locality studied attended antenatal clinics with 92.3 percent of them making 4 or more visits before delivery.
Ajayiet al.,  studied the attitude of pregnant women to a new antenatal care model with four antenatal visits (focused antenatal care) using a cross-sectional survey data and multiple logistic regression analysis in Enugu, Nigeria. Only 20.3% of the parturient desired a change to the new model. The most common reasons for desiring the change were convenience (65.1%) and cost considerations (24.1%).
Awusi, et al.,investigated antenatal care (ANC) services utilization in Emevor village, Isoko South L.G.A of Delta State using a cross-sectional survey data as well as means, percentages and the student’s t test/ chi-square (where applicable) statistical methods. The findings reveal that of the 200 women studied, 113 (57%) utilized antenatal care services during pregnancy while 87 (43%) did not. According to them, the 43% non- utilization rate was very high when compared to the less than 5% reported for industrialized countries. Chuku, examines the role of antenatal care on small size at birth based on the 2003 Nigeria Demographic and Health Survey data with multi-stage cluster sampling procedure. The study finds that antenatal care as measured by tetanus toxoid injections and women who were provided guidance on where to go for pregnancy complications (a proxy for antenatal care) are associated with lower odds of giving birth to small-sized babies suggesting that the content of antenatal care is important in judging its quality and effect.
Fagbamigbeet al, used 2005 National HIV/AIDS and Reproductive Health Survey data and multilevel modeling to examine the determinants of maternal services utilization in Nigeria, with a focus on individual, household, community and state-level factors. The result indicate that only about three-fifths (60.3%) of the respondents used antenatal services at least once during their most recent pregnancy. So far studies have failed to estimate the magnitude of impact of household socioeconomic and other characteristics including the place of antenatal on the likelihood of attending antenatal. Our study is therefore different from these existing studies in Nigeria in the sense that we estimated a count data model of antenatal visits using two demographic and health and surveys data and ascertained the magnitude of impact of various factors on the number of antenatal visits.
Antenatal care (ANC) is the care a pregnant woman receives during her pregnancy through a series of consultations with trained health care workers such as midwives, nurses, and sometimes a doctor who specializes in pregnancy and birth. An analytical review of the recent World Health Statistics showed that ANC coverage, between 2006 and 2013, was indirectly correlated with maternal mortality ratio (MMR) worldwide . This indicates that countries with low ANC coverage are the countries with very high MMR. For instance, ANC coverage in United Arab Emirates was 100% with MMR of 8 per 100,000 and Ukraine had 99% ANC coverage and MMR of 23. By comparison, in sub-Saharan Africa, Ghana had ANC coverage of 96% and MMR of 380/100000, Chad had 43% ANC coverage and a MMR of 980/100,000, and Nigeria had ANC coverage of 61% and MMR of over 560. Nigeria’s MMR is clearly above the African and global average of 500 and 210 respectively. The poor maternal health outcome in Nigeria could be a result of poor ANC utilization although ANC coverage may not provide information on the quality of care provided .
Therefore, this study will conducted to assess factors influencing the utilization of antenatal care and to establish the extent which socio-demographic factors, accessibility, knowledge and quality of care services provided, influence the utilization of antenatal care among pregnant mothers in Ilorin West Local Government Area of Kwara State.
1.2 Statement of Problem
Each year, about 6 million women become pregnant; 5 million of these pregnancies result in child birth .Each year about four million new-borne die in the first week of life worldwide and an estimated 529 000 mothers die due to pregnancy-related causes with maternal mortality rate of 260 per 100,000 live births and a life time risk of 1 in every 140 was recorded in 2008. Available data by the World Health Organization (2014) , show that an estimated 289,000 global maternal deaths were recorded in 2013.
However Africa has a higher number of 190,000 maternal deaths with a maternal mortality rate of 620 per 100,000 live births and a life time risk of 1 in every 32.In the same trend, 287,000 global maternal deaths were recorded in 2010 with Sub Saharan Africa having 56%, South Asia 26% both accounting for 85% global burden of maternal mortality with a global maternal mortality rate of 210 per 100,000 live births and life time risk 0f 1 in every 180. The developed regions recorded a total maternal death of 2,200 with maternal mortality rate of 16 per 100,000 and a life time risk of 1 in every 3800.In 2008 estimates of WHO, UNICEF, UNFPA and World Bank shows that 59,000 Nigerian women died of pregnancy and child birth related cases with a maternal mortality of 840 per 100,000 live births. In 2010 the estimate indicated a decline from 840 to 630 per 100,000 live births [12, 13].
The report also indicates that, Nigeria is among top five countries with highest rates of maternal mortality with about 40,000 pregnant women dying in the country in 2013. Despite the efforts of the State Governments to provide quality health programmes with the establishment of Mother and Child Hospitals, safe motherhood, free medical services for pregnant women and other laudable systems, some pregnant women still patronize traditional birth attendants in Nigeria. However, the rate is higher in the Northern part of Nigeria as maternal deaths occur principally in areas where women have many babies in short time spans due to undernourishment, poor hygienic conditions and lack of access to quality medical treatment. Investigations showed that majority of the pregnant women, especially the illiterates still believed in the efficacy of local herbs and other concoctions given to them by traditional birth attendants despite the high risk associated with it [13, 14].
In Nigeria, it is estimated that approximately 59,000 of maternal deaths take place annually as a result of pregnancy, delivery and post-delivery complications despite the available antenatal health care services. A Nigerian woman is 500 times more likely to die in childbirth than her European counterpart. Mortality ratio is about 800- 1,500/100,000 live births with marked variation between geo-political zones- 165 in south west compared with 1,549 in the North- east and between urban and rural areas [5, 15].
Therefore, this called for effort to investigate these critical factors influencing uptake of ANC and other maternal health services.
1.3 Justification of the Study
Maternal mortality is unacceptably high. About 830 women die from pregnancy- or childbirth-related complications around the world every day. It was estimated that in 2015, roughly 303 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia. More than half of maternal deaths occur in fragile and humanitarian settings. The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus 12 per 100 000 live births in developed countries. There are large disparities between countries, but also within countries, and between women with high and low income and those women living in rural versus urban areas.
In 2013, the global ANC utilization (at least one visit) was 81% while the sub-Saharan Africa ﬁgure was 75% and 61%–66% in Nigeria . This proportion was lower than the 96% reported in a neighboring West African country, Ghana. The proportion attending the recommended minimum of four ANC visits (WHO, 2002) worldwide was 56%, 47% in sub-Saharan Africa, and 51%–57% in Nigeria[16, 1718]. According to the 2013 Nigeria Demographic and Health Survey (NDHS), 33.9% of pregnant women in Nigeria had no contact with any ANC provider . Wide disparities were found in the ANC utilization among states and regions in Nigeria. The lowest ANC utilization in Nigeria was found in Sokoto state with 17.4%, Katsina state 22.7%, Kebbi state 24.3%. Countries have now united behind a new target to reduce maternal mortality even further. One target under Sustainable Development Goal 3 is to reduce the global maternal mortality ratio to less than 70 per 100 000 births, with no country having a maternal mortality rate of more than twice the global average.
1.4 Significance of the Study
The findings of this study will be helpful in policy making and in designing appropriate programs and service for the urban/rural population of Ilorin West Local Government, Kwara State. The reduction of maternal mortality requires early detection of high risk pregnancies through appropriate antenatal care and the existence of a mechanism to ensure timely access to referral facilities. This requires that women should have adequate knowledge about pregnancy related care and should be able to recognize the importance of antenatal care and its utilization. A number of maternal deaths and serious morbidity have been reported in Nigeria in the past. However, there is a related need to know factors which influence the use of antenatal care services that these may be more emphasized in planning.
1.5 Objective of the Study
1.5.1 General Objectives
The purpose of this study was to determine the factors influencing utilization of Antenatal Care services in selected hospital in Ilorin West Local Government Area of Kwara State.
1.5.2 Specific Objectives
- To establish the extent to which socio-demographic factors influences utilization antenatal care service among pregnant women in Ilorin West Local Government Area of Kwara State.
- To determine the influence of knowledge of antenatal care service in the utilization of ANC among pregnant women in Ilorin West Local Government Area of Kwara State.
- To determine the benefit of ANC service among pregnant women in Ilorin West Local Government Area of Kwara State
- To examine the perception of quality of care service rendered and utilization of ANC care services among pregnant women in Ilorin West Local Government Area of Kwara State
- To identify the factors influencing the utilization of ANC service
- To recommend ways to improve the ANC service provided in the public hospital
1.6 Research Questions
- Does the level of education of respondents influence the utilization of antenatal care servicesamong pregnant mothers in Ilorin West Local Government Area of Kwara State?
- Does the knowledge of antenatal care services influence the utilization of antenatal care services among pregnant mothers in Ilorin West Local Government Area of Kwara State?
- Does ANC benefit the pregnant mothers in the selected hospital Ilorin West Local Government Area of Kwara State?
- Does the perception of quality of the care services provided affect the utilization of antenatal care services in selected hospital?
- What are the factors that influences the utilization of ANC?
1.7 Research Hypothesis
- Ho: There is no statistically significant relationship between the level of education of respondents and the utilization of ANC service in some selected public hospitals in Ilorin West LGA.
- Hi: There is statistically significant relationship between the level of education of respondents and the utilization of ANC service in some selected public hospitals in Ilorin West LGA.
1.8 Scope of the Study
The scope of this study covers all pregnant women in selected hospital Ilorin West Local Government Area (General Hospital Ilorin and Cortege Hospital) , and to identify factors that influence the utilization of antenatal care services. This Local Government has been selected as the study location because it is expected to provide larger number of respondents for the study based on their number in strategic locations within the Area.
1.9 Definition of Terms
Means to put to use, especially to make profitable or effective use of something. In this case, it is the effective use of the antenatal care services.
Antenatal Care Services:
Is the care you receive from healthcare professionals during your pregnancy. The purpose of antenatal care is to monitor your health, your baby’s health and support you to make plans which are right for you.
Accessibility refers to the quality of being available when needed.
Is a familiarity, awareness or understanding of someone or something, such as facts, information, descriptions, or skills, which is acquired through experience or education by perceiving, discovering, or learning. In other words, it is awareness or familiarity gained by experience of a fact or situation.
Is the care giving to the mother after delivery
Is defined as the 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 to or aggravated by the pregnancy or its management but not from accidental or incidental causes
Someone who takes care of a person who is young, old or sick. Or a caregiver is a person who is responsible for looking after another person.
The state of carrying a developing embryo or fetus within the female body.
Focus Antenatal Care:
Is the care a woman receives throughout her pregnancy
Expected Date of Delivery:
Is the estimated date of delivery based on gestational age by Us and the Ultrasound date.
Last Menstrual Period:
Is the pregnancy dated in weeks starting from the first day of a woman’s last menstrual period.
A condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and proteinuria.
Discussion of Findings, Conclusion, Limitation, Implication, Recommendation and Suggestion for Further Research.
This chapter deals with the discussion of findings to answer the research questions raised for this study, it will also cover summary of findings, conclusion including contribution to knowledge, limitations, implication to community health, recommendation and suggestion for further research.
5.1 Discussion of findings
5.1.1 Does the knowledge of Antenatal care services influence the utilization of antenatal care services among pregnant mothers in Ilorin West Local Government Area of Kwara State?
The present study has demonstrated that majority of the participating women have knowledge on the importance of ANC services, almost all respondents indicate they know the existence and importance of ANC. It would be expected that knowledge of the role played by ANC would have brought positive results in terms of utilization of the ANC services. However, there has been a downward trend in terms of proportion of women utilizing ANC services. In the present study a very small proportion of respondents had indicated that they use ANC services as recommended by national and WHO protocols
Regarding specific knowledge on recommended number of visits a woman is supposed to make whether or not there is a problem; participating women also demonstrated higher knowledge of recommended visits. More than three quarters of the participating mothers had indicated that 4 visits should be made when there is a problem, however, over two thirds indicated that more than 4 visits should be made when there is a general health or pregnancy related problem. These results demonstrate that the general knowledge among participating mothers on ANC is quite high; nevertheless, knowledge is not translated into utilization as pointed out that only small proportion of participating mothers indicated appropriately utilizes ANC.
5.1.2 Does ANC benefit the pregnant mothers in the selected hospital Ilorin West Local Government Area of Kwara State?
Results of the study have also demonstrated that respondents have adequate knowledge on the benefits of utilizing ANC services. One of the most prominent benefits cited by participating mothers was that ANC help to identify complications, prepared woman for labour, Identify unhealthy conditions such as hypertension etc. This finding is in agreement with Hollander 34 who found rapport building amongst women using antenatal care services as a pre-requisite for continuation of service utilization. Other benefits mentioned are shown in Table 6. Adequate knowledge on ANC services would contribute to reduction in maternal mortality rate, as suggested by the WHO . The study further established that participating mothers were aware that individualized health education amongst the service users assists in transferring of knowledge from service providers to pregnant women.
5.1.3 Does the perception of quality of the care services provided affect the utilization of antenatal care services in selected hospital?
According to the study findings, majority of the participants perceived the quality of service provided during ANC clinics as good. However, most of the participants were not comfortable receiving ANC services together with older women. The findings were further strengthened by responses from the key informants’ interviews in which those interviewed reported that teenage mothers fear judgment and ridicule from older women.
This findings I line with that of Fagbamigbeet al. who stated that almost all the respondents (94%) attended antenatal care services. Six percent of the respondents did not attend antenatal care services. As to the places of attendance, the majority of antenatal care services attended Public health facilities 79%, private health facilities 15% and Traditional Birth Attendant 6%. The reasons for the choice of place for antenatal care services included proximity (69 %), good staff attitude 15% and free services 10%. The others were quality of services 4%, safe delivery and no delays 2%. Only less than one percent (0.4 %), indicated that they made those choices without any reason and because there was no alternative. Seventy 58 one percent (71%) of the respondents indicated one staff attended to them during the antenatal care session. The attitude of the health providers was good as claimed by most of the respondents (87%). However, only 5% said otherwise. This however is in contrast to what Carroli et al., , wrote in her thesis “Factors Influencing adolescents’ utilization of Antenatal care services in Bulawayo.” She claimed that pregnant adolescents were not satisfied with services rendered hence poor or non-utilization.
5.1.4 What are the factors that influences the utilization of ANC?
The study further explored socio-cultural factors which would affect utilization of ANC in the study area. Almost all of the participating mothers indicated that sociocultural factors played a greater role in low utilization of FANC services. Distance to the health facility significantly determined both the probability and frequency of attending ANC clinics. Longer distance to the health facility is indicated as highly associated with few visits. These findings are consistent with other studies Lubbock et al.  interestingly, the study also found that timely starting ANC earlier is a sign of bragging or showing off to fellow women who are not pregnant and have no children. This resulted in low utilization of ANC as reflected in few number of 47 antenatal visits women made. To the researcher’s knowledge, this is the first study to report that fear of being perceived as showing off the pregnancy contributes to low utilization of ANC, thus further research on the subject can facilitate formulation of education messages to improve utilization of ANC.
Furthermore, the study elucidated that seeking permission to go for antenatal care is significantly associated with low utilization of ANC, on a similar note, participating mothers who were waiting to seek permission made significantly fewer than required number of visits for ANC, this practice has been reported elsewhere, Babalolaet al. Apparently this study showed that husbands (79%) mostly gave permission to start utilizing ANC, implying that male dominance in decision making on women reproductive deserves more attention in order to minimize negative impacts but maximize desirable issues. So that instead of women seeking permission they should ask for husband involvement in antenatal care services. This thinking is equally supported by Onasogaet al. who argues that pregnant women who first sought permission from husbands before utilizing ANC services are likely to make fewer than required number of visits.
Matua,  reported that pregnant women have reported negative attitudes of health care providers. He said that women are sometimes reluctant to use maternity care services because health care providers are perceived to be rude, insensitive and threatening to the young mothers. As to the waiting time, sixty nine percent (69%) of the respondents waited for about 60 minutes before services were rendered while 27% waited for less than 40 minutes. Whereas 6% of respondents were not satisfied, 69% indicated that on average they were satisfied with the services provided at the antenatal care they attended
5.2 Summary of Findings
The study revealed that women in the study area have good knowledge on ANC, the study also shows that respondents are aware of the benefit of ANC which includes, to identify problems such as hypertension, mal-presentation of baby etc. they also rate the quality of services rendered as good, finally study have identify several factors that influences ANC utilization to includes, long distance to access the service, attitude of services provider, socio-economic factors, husband consent etc.
The study has shown that almost all pregnant women in the study area have at least some knowledge of the ANC. Thus this study demonstrates that knowledge of ANC in general and its benefits is quite high among pregnant women in the study area. Furthermore, the present study has shown that socio-economic factors, distance, husband consent, attitudes of services provider etcare factors associated with low utilization of ANC among pregnant women. Long distance to health facilities, perception of showing off or bragging about the pregnancy, as well as individual choice of not wanting to make many visits also contributed to low utilization of ANC among pregnant women in the study area. The present study has also demonstrated that seeking permission to utilize ANC significantly contributed to low utilization of ANC by pregnant women. The study had shown that all health care workers in the antenatal sections were trained in reproductive health and ANC in general. Women in the present study demonstrated a positive perception towards the care of ANC service, although, there are factors affecting these utilization of the services.
5.4 Limitation of the Study
The smallness of the sample size, especially from the study area would make the estimate and the dependent and independent variables unstable and therefore undetected. However, a larger size from the study area (state or zone) will be a good study among lactating mothers. Also the distortion can occur with the use of self-administered questionnaire; the social desirability bias where the respondents will tend to give answer they feel is socially desirable to the researcher, I case this information will go to the authorities at the ministry of health.
5.5 Recommendations of the Study
The study findings unveiled a number of factors in the provision of antenatal care services leading to utilization.
The following are therefore recommended based on the findings.
- The Ministry of Health should review and strengthen reproductive health programs and ensure that they are friendly and are need focused.
- Continuous disseminating of information by the Ministry of Hhealth on antenatal care, delivery and postnatal care services to enhance accessibility by every pregnant woman.
- Spouses of pregnant women should be encouraged by their partners to support them to access the ANC services.
- Information, education and communication strategies promoting health seeking behaviours should be enhanced both at health facility and community level. Some of the issues to be intensified should be dispelling myths associated with pregnancy, informing communities that any pregnant woman is at risk and requires medical attention during the entire pregnancy period.
- Communities should further be informed that regardless of age of the woman and parity all pregnant women must be supported to utilize ANC services.
- The government, communities and other development partners should increase health infrastructure so that distance to the health facility can be reduced. This will allow pregnant women to fully benefit from ANC services.
- Communities should be assisted to come up with strategies which will promote utilization of ANC services for instance agreeing to reward families adhering with maternal and child health established policies.
- There should be multi-sectoral approach to promotion of maternal and child health.
5.6 Suggestions for Further Study
Further studies should apply different research instruments like focused group discussions to involve respondents in discussions in order to generate detailed information which would help improve delivery of ANC services.
There is need to conduct larger prospective studies to better understand on a national level ANC utilization. This will help to establish in-depth qualitative data on demographic and social-cultural issues affecting FANC utilization.
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