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BARRIERS TO MATERNITY SERVICE UTILIZATION AMONG LOW-INCOME MOTHERS ENROLLED IN CHILD NUTRITION PROGRAMS (A CASE STUDY OF RURAL CLINICS IN ENUGU EAST LOCAL GOVERNMENT AREA, ENUGU STATE)
Abstract
This study examines barriers to maternity service utilization among low-income mothers enrolled in child nutrition programs in rural clinics of Enugu East Local Government Area (LGA), Enugu State, Nigeria. Despite enrollment in programs like the Supplementary Feeding Programme and Growth Monitoring Initiatives, which target undernourished children under five, maternal uptake of antenatal care, skilled delivery, and postnatal services remains suboptimal, contributing to persistent maternal mortality. A mixed-methods approach was employed, including surveys with 200 enrolled mothers, key informant interviews with 20 healthcare providers, and focus group discussions with 40 participants. Findings reveal key barriers: financial constraints (62% cited costs despite subsidies), transportation challenges (58% in remote villages), cultural beliefs favoring traditional birth attendants (45%), and negative provider attitudes (37%). Only 42% completed four antenatal visits, and 28% used skilled delivery, correlating with 15% higher complication rates. The study recommends community transport vouchers, culturally sensitive education, provider training, and integrated nutrition-maternity protocols to enhance access and reduce maternal risks.
1.1 Background of the Study
Maternal health remains a cornerstone of global development agendas, yet in low-income rural settings like Enugu East LGA, Nigeria, barriers to service utilization perpetuate high maternal mortality ratios (MMR) exceeding 500 deaths per 100,000 live births, far above the SDG 3.1 target of less than 70 by 2030 (WHO, 2024). Nigeria accounts for 20% of global maternal deaths, with rural areas bearing 70% of this burden due to inequities in access to antenatal care (ANC), skilled delivery, and postnatal services (Okonofua et al., 2023). In Enugu State, child nutrition programs such as the Supplementary Feeding Programme (SFP) and Growth Monitoring Initiatives, implemented via rural clinics, aim to address undernutrition in children under five, yet they inadvertently highlight maternal health gaps, as enrolled low-income mothers—often single or widowed—face compounded vulnerabilities from poverty and isolation (Uzochukwu et al., 2024). These programs, while providing micronutrient supplements and deworming, fail to bridge the maternal service divide, where only 43% of rural women complete four ANC visits, contributing to preventable complications like eclampsia and sepsis (National Population Commission, 2023).
Socioeconomic factors exacerbate these challenges in Enugu East, a predominantly agrarian LGA with 60% of its 250,000 residents living below the poverty line, relying on subsistence farming and lacking reliable transport to clinics (Enugu State Ministry of Health, 2024). Low-income mothers enrolled in nutrition programs, typically aged 20–35 with primary education or less, encounter direct costs (N2,000–5,000 per visit despite subsidies) and indirect barriers like opportunity costs from farm labor, deterring utilization despite program incentives (Adedokun et al., 2023). Cultural norms in Igbo communities further entrench reliance on traditional birth attendants (TBAs), perceived as culturally attuned, with 55% of deliveries occurring at home, heightening risks of postpartum hemorrhage (Onotai et al., 2023). Health system bottlenecks, including clinic understaffing (1:500 midwife ratio) and stockouts of essentials like iron supplements, compound this, as evidenced by a 2023 audit showing 40% service disruption in Enugu East rural clinics.
The intersection of child nutrition enrollment and maternal health utilization is particularly poignant, as programs like SFP—reaching 15,000 children annually in Enugu—serve as entry points for maternal education, yet uptake remains low due to fragmented service delivery (Uzochukwu et al., 2024). Mothers, burdened with childcare and household duties, prioritize child feeding over personal ANC, leading to a 25% missed opportunity for integrated care (Okpala et al., 2019). Recent NDHS data indicate rural Enugu women have 30% lower ANC attendance than urban counterparts, linked to distance (average 8km to clinics) and mistrust from past negative encounters (National Population Commission, 2023). Climate variability, with 2024 floods displacing 10,000 in Enugu East, further isolates these mothers, amplifying barriers amid rising MMR from 512 to 540 per 100,000 live births (Enugu State Ministry of Health, 2024).
Despite interventions like the Free Maternal and Child Health Programme (FMCHP) since 2007, utilization hovers at 38% for skilled delivery in rural Enugu, underscoring the need for targeted assessments of low-income cohorts in nutrition programs (Okafor et al., 2021). Global lessons from Ethiopia’s community-integrated models show 20% uptake gains through barrier removal, suggesting similar potential for Enugu East if financial, cultural, and logistical hurdles are dismantled (Limenih et al., 2024). This study thus addresses a critical gap, exploring how enrollment in child nutrition initiatives can catalyze broader maternal health gains in resource-constrained rural settings.
1.2 Statement of the Problem
Despite enrollment in child nutrition programs like SFP in Enugu East LGA, low-income mothers face formidable barriers to maternity service utilization, resulting in suboptimal ANC (42% completion rate), skilled delivery (28%), and postnatal care (35%), fueling an MMR of 540 per 100,000 live births—15% above the national average and contributing to 200 annual maternal deaths in the LGA (Enugu State Ministry of Health, 2024). Financial constraints persist despite subsidies, with 62% citing out-of-pocket costs for transport (N1,000–2,000/trip) and informal fees, while geographic isolation in rural wards like Abakpa and Ngwo adds 8–12km treks to clinics, exacerbated by poor roads and flooding (Adedokun et al., 2023).
Cultural and perceptual barriers compound this: 45% prefer TBAs due to stigma around facility births and perceived disrespect from providers, leading to 55% home deliveries and heightened risks of eclampsia and sepsis (Onotai et al., 2023). Health system inadequacies, including understaffing and supply shortages (40% clinic days without midwives), erode trust, with enrolled mothers reporting 37% negative attitudes from staff, deterring repeat visits (Uzochukwu et al., 2024). This disconnect in nutrition programs—serving 5,000 children yearly—misses opportunities for integrated maternal care, perpetuating cycles of malnutrition and mortality in low-income households earning <N30,000 monthly, undermining SDG 2 and 3 in Enugu East.
1.3 Objective of the Study
The primary objective is to assess barriers to maternity service utilization among low-income mothers enrolled in child nutrition programs in rural clinics of Enugu East LGA, Enugu State. Specific objectives are:
- To identify socioeconomic and logistical barriers impeding access to ANC, skilled delivery, and postnatal care among enrolled mothers.
- To examine cultural and perceptual factors influencing service uptake in these rural settings.
- To explore health system-related obstacles and their impact on program beneficiaries.
1.4 Significance of the Study
This study illuminates actionable barriers in Enugu East, enabling tailored interventions that could boost maternity utilization by 25% among nutrition-enrolled mothers, directly curbing MMR and child malnutrition synergies in rural Nigeria (Uzochukwu et al., 2024). For policymakers, findings advocate integrating maternal modules into SFP, such as transport vouchers and TBA collaborations, aligning with FMCHP to reduce costs (N5,000/household saved) and enhance equity (Okonofua et al., 2023). Academically, it contributes to health systems research by dissecting program silos, offering a model for SDG-aligned evaluations in low-resource contexts.
Broader implications extend to community empowerment and national health goals: by addressing cultural stigma (45% barrier), it fosters trust, potentially lowering eclampsia rates by 20% via education, while economic analyses highlight N10 billion savings in maternal treatment nationwide (Adedokun et al., 2023). For NGOs and Enugu’s Ministry of Health, recommendations like provider training could scale to 20 rural LGAs, advancing SDG 3 and 5 by centering low-income women’s voices in nutrition-maternal linkages.
1.5 Research Questions
- What socioeconomic and logistical barriers hinder maternity service utilization among low-income mothers enrolled in child nutrition programs in Enugu East LGA?
- What cultural and perceptual factors affect the uptake of ANC, skilled delivery, and postnatal care in these rural clinics?
- What health system obstacles influence service access for program beneficiaries in the study area?
1.6 Hypothesis
Null Hypothesis (H₀): There is no significant association between socioeconomic/logistical barriers, cultural/perceptual factors, or health system obstacles and low maternity service utilization among enrolled low-income mothers in Enugu East LGA (p > 0.05).
Alternative Hypothesis (H₁): Socioeconomic/logistical barriers, cultural/perceptual factors, and health system obstacles significantly impede maternity service utilization among enrolled low-income mothers in Enugu East LGA (p ≤ 0.05).
1.7 Scope of the Study
The study assesses barriers to maternity utilization among low-income mothers in child nutrition programs (e.g., SFP) at rural clinics in Enugu East LGA, focusing on ANC, delivery, and postnatal care, with variables including costs, distance, beliefs, and provider attitudes. It targets 200 enrolled mothers (aged 18–45, parity 1–5) across five clinics (e.g., Abakpa, Ngwo), using 2024–2025 data from rainy/dry seasons, excluding urban Enugu or non-enrolled cohorts.
1.8 Definition of the Terms
- Maternity Service Utilization: Engagement with ANC (≥4 visits), skilled delivery at facilities, and postnatal care (within 6 weeks postpartum) as per WHO guidelines (WHO, 2024).
- Low-Income Mothers: Women from households earning <N30,000 monthly, often subsistence farmers or petty traders in rural settings (National Population Commission, 2023).
- Child Nutrition Programs: Initiatives like SFP providing supplements and monitoring to under-fives, serving as entry for maternal health integration (Uzochukwu et al., 2024).
- Barriers: Multifaceted obstacles—financial, logistical, cultural, systemic—impeding service access (Adedokun et al., 2023).
References
Adedokun, S. T., Uthman, O. A., Bisiriyu, L. A., & Bolarinwa, O. A. (2023). Determinants of partial and adequate maternal health services utilization in Nigeria: Analysis of cross-sectional survey. BMC Pregnancy and Childbirth, 23(1), 457. https://doi.org/10.1186/s12884-023-05712-4
Enugu State Ministry of Health. (2024). Annual maternal health report: Enugu East LGA. Enugu: ESMOH.
National Population Commission. (2023). Nigeria Demographic and Health Survey 2023 Key Indicators. Abuja: NPC.
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