CHAPTER ONE

Introduction

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^[1]. 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^[1]. 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 ^[1]. 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)^[2].

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^[2] 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^[2]. 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^[3], 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^[4]. 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, Ibeh^[5]studied 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., ^[6] 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.,^[7]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^[8], 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,^[9] 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 ^[9]. 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 ^[10].

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 ^[5].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) ^[11], 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]}.