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DETERMINANTS OF ANTENATAL CARE UTILIZATION IN RURAL NORTHERN NIGERIA: A CASE STUDY OF GIWA GENERAL HOSPITAL, KADUNA STATE

CHAPTER ONE 

INTRODUCTION

1.1 Background to the Study

ANTC is a foundation of maternal and newborn health, which offers these women and their unborn babies with essential promote, preventive and curative health services. Other organizations throughout the world recommend at least eight ANC contacts beginning in the first trimester, designed to decrease maternal and perinatal morbidity and mortality (WHO, 2016). Nevertheless, low- and middle-income nations, with the notable exception of those found in sub-Saharan Africa, are reporting terrifyingly low ANC utilization rates due to this recommendation.

It is estimated that Nigeria has a disproportionate English maternal mortality burden, with the country accounting almost two-thirds of the total world 28.5% of all women dying in childbirth (UN Report on Trends in Maternal Mortality 2023). The maternal mortality rate of 1,047 deaths per 100,000 live births in 2020 in Nigeria makes the country one of the most unsafe places worldwide to give birth (WHO/UNICEF, 2023). Northern Nigeria plays a bigger role in these statistics, with highly established socialeconomic disparities, patriarchal behaviors, religious impacts, and unimaginative health facilities.

Kaduna State in the North-West geopolitical zone and with a projected population of more than 9 million as of 2022 is one of the examples of the problem of maternal health in rural northern Nigeria. The state has been experiencing low ANC attendance, low facility-based deliveries, and low reception of suggested ANC elements (Adewuyi et al., 2024). Literature has found consistently and solely rural residence, low maternal and spousal education, high parity, and poverty to be the predominant forces behind poor ANC utilization in the area (Oguntunde et al., 2017). Moreover, national statistics show that the rural reaction to the covid-19 pandemic is incredibly rural-urban: urban women are at much higher risk of having at least four ANC visits than rural women (Adewuyi et al., 2024).

The Nigerian Demographic and Health Survey (NDHS) 2018 indicated that the total ANC coverage was 61% with a high range variation in coverage between regions and wealth quintiles. There are some small gains that have been realized through the existing interventions, such as the Midwives Service Scheme (MSS), free maternal health policies, and community-based antenatal programs. Nonetheless, gaps in their implementation, lack of funding, and sociocultural influences still restrict impact, particularly in rural Kaduna. In 2024, a recent group antenatal care (gANC) programme initiated in Kaduna and Kano States has tried to fill these gaps, with baseline statistics of more than 1,200 pregnant women showing impressive initial engagement levels (Aliyu et al., 2024). Still, little is known about the ANC-utilization determinants specific to rural Kaduna.

1.2 Statement of the Problem

After years of national maternal health initiatives, the use of ANC in rural Northern Nigeria is at a crippling rate. Kaduna State has a complex set of obstacles to overcome in rural communities such as distance to health facilities, financial aspects, cultural and religious factors reducing women mobility and lack of awareness regarding the value of antenatal care in rural areas. Research shows that in northern Nigeria less than half of all rural women receive the suggested four or more ANC visits, and the percentage starting ANC in the first trimester is even less (Dahiru & Oche, 2015).

The impacts of poor ANC use are immense: loss of early detecting pregnancy complications like pre-eclampsia, gestational diabetes and anaemia; immunization against tetanus; preventive malaria malady and birth preparedness training. This is a direct contributor to the high maternal and neonatal death rates in Nigeria. Although this fact exists, few population-specific studies on the determinants of ANC utilization in the rural areas of Kaduna State are done, especially those that have included recent data that capture the current health system environment following the COVID-19. This knowledge gap hinders the creation of the evidence-based interventions that are guided. This paper thus aims to fill this gap by rigorously evaluating the factors that drive ANC use among women in rural Kaduna State.

1.3 Aim of the Study

To assess the determinants of antenatal care utilization among pregnant women in rural communities of Kaduna State, Nigeria.

Specific Objectives

1. To assess the level of ANC utilization (number of visits and timing of first visit) among women of reproductive age in rural Kaduna State.
2. To determine the sociodemographic factors (education, income, parity, religion, and marital status) associated with ANC utilization.
3. To identify the perceived barriers to ANC utilization among women in rural Kaduna State.
4. To evaluate the influence of male partner support and community-level factors on ANC attendance.
5. To assess the relationship between health facility accessibility and ANC utilization in the study area.

1.4 Research Questions

1. What is the level of ANC utilization among women of reproductive age in rural Kaduna State?
2. What sociodemographic factors are associated with ANC utilization in the study area?
3. What are the perceived barriers to ANC utilization among women in rural Kaduna State?
4. How does male partner support influence women’s ANC attendance?
5. What is the relationship between health facility accessibility and ANC utilization?

1.5 Research Hypotheses

• H₀: There is no significant association between maternal education level and ANC utilization in rural Kaduna State.
• H₁: There is a significant association between maternal education level and ANC utilization in rural Kaduna State.
• H₀: There is no significant association between household wealth status and ANC utilization.
• H₁: There is a significant association between household wealth status and ANC utilization.

1.6 Scope of the Study

The cohort of reproductive age women (15-49 years) already pregnant at least once within the last five years but living in the rural settlements of the Kaduna State, Nigeria will be targeted by this study. The three rural local government areas (LGAs) to be studied will be in three senatorial districts of Kaduna State (Kaduna North, Kaduna Central and Kaduna South). The variables of interest will comprise ANC attendance frequency, the first ANC visit timeline, sociodemographic, distance to a health facility, perceived barriers, and male partner presence. The research will take place in the 2024-2025 academic year.

1.7 Significance of the study

This research is important in several aspects. To the policymakers and the Kaduna State Ministry of Health, the results will present evidence which can be used to develop specific interventions in line with the attainment of certain barriers to ANC attendance in the rural setting. The research will be part of the greater impact of Nigeria on attaining the Sustainable Development Goal 3.1, the target of which is to reduce the maternal mortality rate in the world to less than 70 deaths per 100,000 live births by 2030. In the case of community-based communication strategies applied by healthcare workers and community health workers deployed in Kaduna State, the results will inform the strategy of addressing the local socioeconomic and cultural determinants. Literaturewise, the study contributes to the scarcity of rural-specific ANC determinants studies in the Kaduna State and serves as a starting point to longitudinal studies. The results will also aid the community leaders and NGOs, as well as international development partners working in the northern part of Nigeria so that the way the interventions are structured can have the greatest impact on maternal health outcomes.

1.8 Operational Definition of Terms

• Antenatal care utilization: Attendance at a health facility or structured community-based clinic for pregnancy-related care, measured by the number of ANC contacts and the gestational age at first contact.
• Rural community: A settlement characterized by low population density, limited access to health facilities, and predominantly agrarian livelihoods, as classified by the National Population Commission (NPC) of Nigeria.
• Determinants: Factors, including sociodemographic, economic, cultural, and geographic variables, that influence a woman’s decision to seek and utilize antenatal care services.
• Male partner support: Active involvement of the husband or male partner in encouraging, accompanying, or financially supporting the pregnant woman’s ANC visits.
• Adequate ANC: Receipt of at least eight ANC contacts beginning in the first trimester (before 12 weeks of gestation), as recommended by WHO (2016).

References

Adewuyi, E. O., Auta, A., Adewuyi, M. I., Philip, A. A., Olutuase, V., Zhao, Y., Khanal, V., & Ortega, J. A. (2024). Antenatal care utilisation and receipt of its components in Nigeria: Assessing disparities between rural and urban areas  A nationwide population-based study. PLOS ONE, 19(7), e0307316. https://doi.org/10.1371/journal.pone.0307316

Aliyu, M. H., Olagunju, O. S., Gwarzo, G. D., Ahmad, A., Ahmad, I., Yakubu, A., Bello, M., Oguntunde, O., Pindiga, H. U., & Yakasai, I. A. (2024). Implementation and baseline evaluation of an evidence-based group antenatal care program in two Nigerian states. BMC Pregnancy and Childbirth, 24(1), 1-15. https://doi.org/10.1186/s12884-024-06700-4

Dahiru, T., & Oche, M. O. (2015). Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan African Medical Journal, 21, 321. https://doi.org/10.11604/pamj.2015.21.321.6527

Federal Ministry of Health (FMoH). (2019). Nigeria Demographic and Health Survey 2018. National Population Commission and ICF International.

Oguntunde, O., Passano, P., Lawoyin, T., Mundi, J., & Okonofua, F. (2017). Antenatal care and skilled birth attendance in three communities in Kaduna State, Nigeria. African Journal of Reproductive Health, 21(2), 39-47. https://doi.org/10.29063/ajrh2017/v21i2.5

World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. WHO Press.

World Health Organization, UNICEF, UNFPA, World Bank, & UN DESA. (2023). Trends in maternal mortality 2000 to 2020. WHO Press. https://www.who.int/publications/i/item/9789240068759