Patterns, determinants, and outcomes of antenatal care services utilization among rural and urban women in north-western Nigeria: A comparative analysis

Victoria Nanben Omole; Samuel Amos Bayero; Mohammed Jimoh Ibrahim; Nafisat Ohunene Usman; Onyemocho Audu; Caleb Mohammed

doi:10.4103/ijmh.IJMH_72_20

ORIGINAL ARTICLES

Year : 2021 | Volume : 26 | Issue : 3 | Page : 147-162

Patterns, determinants, and outcomes of antenatal care services utilization among rural and urban women in north-western Nigeria: A comparative analysis

Victoria Nanben Omole¹, Samuel Amos Bayero², Mohammed Jimoh Ibrahim¹, Nafisat Ohunene Usman¹, Onyemocho Audu³, Caleb Mohammed⁴
¹ Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna, Nigeria
² Barau Dikko Teaching Hospital/College of Medicine, Kaduna State University, Kaduna, Nigeria
³ Department of Epidemiology & Community Health, College of Health Sciences, Benue State University, Makurdi, Nigeria
⁴ Department of Obstetrics and Gynaecology, College of Medicine, Kaduna State University, Kaduna, Nigeria

Date of Submission	29-Nov-2020
Date of Decision	28-Jan-2021
Date of Acceptance	08-Feb-2021
Date of Web Publication	20-Apr-2021

Correspondence Address:
Victoria Nanben Omole
Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna.
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_72_20

Abstract

Background: Antenatal care (ANC) services have been globally lauded as having positive effects on pregnancy outcomes and reducing maternal and perinatal mortalities. However, the utilization of ANC is not uniform among its target population, particularly in rural areas of sub-Saharan Africa and south Asia. Objective: The objective is to ascertain and compare the patterns, determinants, and outcomes of ANC utilization among rural and urban women of child-bearing age in Kaduna State, north-western Nigeria by using a comparative, community-based, cross-sectional, descriptive study design among 340 women in a rural (n = 170) and an urban (n = 170) community. Materials and Methods: Respondents were selected by cluster sampling and multistage sampling methods in the rural and urban areas, respectively. Data were collected by using a structured, self-administered questionnaire and analyzed by using Statistical Package for Social Sciences (SPSS), version 25. Results were presented in tables, and associations were tested by using chi-square (x²) test. Results: Most of the respondents were between 25 and 29 years, more than 80% were married, and only 23.5% (rural) and 38.8% (urban) had a post-secondary level of education. The ANC attendance was 61.8%, representing 210 out of the 340 respondents (rural 40.6%, urban 82.9%). Among the ANC attendees, 71% initiated ANC in the first trimester (rural 60.9%, urban 75.9%) and 61.4% had at least four visits (rural 56.5%, urban 63.8%). The determinants of ANC utilization were mainly levels of education and incomes of the respondents and/ or their husbands. Conclusion: A consistent pattern of rural–urban disparities was demonstrated in diverse aspects of ANC utilization, including the determinants and outcomes thereof, with better indices among urban women relative to rural women. These findings underscore the need to bridge the gap between rural and urban areas. Priority attention needs to be given to the spatial (geographical) siting of health facilities, literacy, and financial standing of both women and their husbands.

Keywords: Antenatal care (ANC), rural, urban, utilisation, women

How to cite this article:
Omole VN, Bayero SA, Ibrahim MJ, Usman NO, Audu O, Mohammed C. Patterns, determinants, and outcomes of antenatal care services utilization among rural and urban women in north-western Nigeria: A comparative analysis. Int J Med Health Dev 2021;26:147-62

How to cite this URL:
Omole VN, Bayero SA, Ibrahim MJ, Usman NO, Audu O, Mohammed C. Patterns, determinants, and outcomes of antenatal care services utilization among rural and urban women in north-western Nigeria: A comparative analysis. Int J Med Health Dev [serial online] 2021 [cited 2023 Jun 6];26:147-62. Available from: https://www.ijmhdev.com/text.asp?2021/26/3/147/313957

Introduction

Antenatal care (ANC) services are globally recognized and acknowledged as essential and vital life-saving interventions for both mother and child. The World Health Organization (WHO) defines “ANC” as the care (or services) provided during pregnancy by skilled healthcare professionals to pregnant women to ensure the best health outcomes for both mother and baby.^[1] The provision and utilization of these services are particularly pertinent in developing countries of the world, where both maternal and childhood morbidity and mortality indices have been shown to be public health concerns. For instance, about 86% of the global maternal mortality burden (representing approximately 254,000 deaths) is borne by nations in sub-Saharan Africa and southern Asia.^[2] Furthermore, sub-Saharan Africa bears about 67.6% (two-thirds) of the global burden, with Nigeria being categorized among 15 nations with high maternal mortality indices.^[2] The perinatal mortality burden is not any different, as the aforementioned regions account for about 95% of these deaths.^[3] Nigeria is reported to record the highest perinatal mortality rate in West Africa and the second highest in sub-Saharan Africa, after Lesotho.^[3]

Antenatal care, when initiated early in pregnancy and offered within the context of the minimum recommended standards (such as early risk identification by diverse screening methods, and prevention, detection, and management of pregnancy-related complications and diseases as well as health education and promotion), has been shown to significantly improve the maternal and early neonatal outcomes of pregnancy.^{[1],[2],[3],[4],[5]} Both the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs) advocate the provision of reproductive health services (including ANC) to reach all women, particularly the deprived and/or disadvantaged women of low and medium income countries (LMIC) of the world.^[2],[6] Although the provision of and access to ANC services are fundamental rights of women across the globe,^[1],[4] the utilization of the same is also another important aspect that is crucial in ensuring desirable outcomes for both mothers and babies.^[7] Bearing in mind that globally, factors such as provision of, access to, and end-user utilization of most public health services vary from place to place,^[6] this study’s objective is to ascertain and compare the patterns, determinants, and outcomes of ANC utilization among rural and urban women of child-bearing age in Kaduna State, north-western Nigeria.

Materials and Methods

Study Areas

The study was conducted in two areas (a rural and an urban location). The rural area is Sabon Birni ward in Lere Local Government Area (LGA), in the northern senatorial zone of Kaduna State. The LGA has a current projected population of 458,600 people. Sabon Birni ward has an estimated population of 50,148 people; women of child-bearing age (15–49 years) constitute about 11,033 people. The area consists mainly of hamlets and farm compounds. It is multiethnic in nature, and the predominant occupations include farming, fishing, and trading. There is a PHC clinic in the community. The urban study area is Ungwan Rimi, located in Kaduna metropolis (the State capital) in Kaduna North LGA, which is entirely urban. The LGA has a current projected population of about 492,100 people. Health facilities of all three tiers of the healthcare system (both public and private) exist therein.

Study Design

A comparative, community-based, cross-sectional, descriptive study design

Study Population

All women within the reproductive age group (15–49 years) residing within the two study areas

Sample Size

The sample size was calculated by using the formula:

where n is the desired sample size; z the standard normal deviate that corresponds to 95% confidence interval (usually set at 1.96); p = the prevalence of ANC utilization as obtained from a previous, similar study^[8] 67% (ie, 0.67); q = 1—P = 33% (ie, 0.33); and d is the degree of precision (0.05).

n = 339.75 = 340.

Sampling Method

Overall, 340 respondents participated in the study (170 per location: rural and urban). Participants were selected in the rural area using a single-stage, cluster sampling technique. Sabon Birni was divided into 12 clusters, according to its existing 12 hamlets (each hamlet representing a cluster). Five clusters were selected by simple random sampling (by balloting); the consenting women of child-bearing age within these selected clusters were recruited to participate in the study until the sample size of 170 was attained. Multistage sampling technique was used in the urban area. In the first stage, five out of the 37 major streets in the study area (Ungwan Rimi) were selected by simple random sampling (by balloting). In the second stage, houses on the selected streets were numbered; odd-numbered houses were selected by the systematic sampling method. In the final stage, all consenting women of child-bearing age in the selected houses were consecutively recruited to participate in the study until the sample size of 170 respondents was attained.

Data Management

Data were collected by using a structured, open- and close-ended, self-administered questionnaire (except in cases where respondents were illiterate). Data were analyzed by using SPSS (version 25). Results were presented in tables. Chi-square (χ²) test was used to test for associations (P ≤ 0.05)

Ethical Considerations

Ethical approval was secured from the Ethical Committee of Barau Dikko Teaching Hospital (BDTH), Kaduna, Kaduna State. Informed consent was obtained from the respondents, and their privacy as well as the confidentiality of the information obtained from them was assured.

Results

Most respondents were aged 25 to 29 years (29.4%). More than 80% were married; 23.5% and 38.8% in the rural and urban areas, respectively, had post-secondary education. About 49.4% and 32.9% of the rural and urban women, respectively, were housewives. Respondents were very similar in age distribution and marital status. About 27.8% and 61.7% of the respondents’ husbands had a post-secondary level of education in the rural and urban locations, respectively. At least 49.7% of the respondents’ husbands in the urban areas had formal (white collar) jobs, whereas 47.2% of those in the rural areas were (peasant) farmers. About 35.1% and 24.2% of the women in the rural and urban areas, respectively, did not know their husbands’ income(s).

About 82.9% of the urban women attended ANC, whereas only 40.6% of the rural women did. Out of the 210 respondents who attended ANC, 77.6% went to government-owned facilities. ANC attendance was initiated in the first trimester by 60.9% and 75.9% of rural and urban respondents, respectively. About 56.5% and 63.8% of rural and urban respondents, respectively, had at least four visits. The pregnancy outcome was live births for 91.5% of the respondents (89.4% rural and 93.5% urban). Aside from pregnancy outcomes, both study groups significantly differed in all aspects of ANC utilization (P ≤ 0.05).

All variables were statistically significant in determining ANC attendance in both study groups (except for age and parity among rural women; and age among urban women).

Age was the only statistically significant determinant of the choice of type of health facility attended for ANC among the rural respondents; whereas respondents’ level of education and parity as well as their husbands’ level of education and income were significant for the urban women.

No variable was statistically significant in determining the time of initiation of ANC attendance among the rural women; however, for the urban women, their level of education and parity, and their husbands’ level of education and income were significant.

Respondents’ income was the only statistically significant determinant of the number of ANC visits among rural respondents.

Tribe, level of education, and parity of urban respondents as well as their husbands’ level of education were statistically significant determinants of the total number of ANC visits.

Respondents’ tribe and their husbands’ level of education and income were statistically significant determinants of pregnancy outcome among the rural women; whereas respondents’ tribe and their level of education were significant among the urban women.

Discussion

Women in their twenties (20–29 years) were the majority among the rural respondents, whereas women in the age group of 25 to 34 years constituted the majority in urban areas [Table 1]. This is consistent with findings in the most recent National Demographic and Health Survey (NDHS-2018).^[8] This may not be unconnected with the custom of early marriage widely practiced in the rural north of the country as well as the tendency for females in urban areas to be enrolled in school for longer periods before engaging in marriage.^[8],[9],[10] Furthermore, the respondents and their husbands differed significantly across study areas in their levels of education, occupations, and monthly incomes [Table 1]. This also concurs with the findings of NDHS-2018, depicting a typical rural–urban variation of most socioeconomic features, as is also obtainable in many developing countries.^[8],[11]

Table 1: Demographic and Socioeconomic Profile of Respondents and Their Husbands (n = 340)

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The overall ANC attendance across both study areas in this study is 61.8% (rural 40.6%, urban 82.9%), which is below the national average of 67% (rural 56.1%, urban 83.6%).^[8] This rural–urban disparity was also reported in a Bangladeshi study where about 74.8% of urban women received ANC compared with only half (50.9%) of their rural counterparts,^[12] but it contrasts the findings from a study in south-eastern Nigeria, where both rural and urban areas recorded 92% ANC attendance.^[13] The ANC attendance is generally low in the northern part of the country, ranging from 53.9% in the north-western zone (where this study was conducted) to 66.2% in the north-central zone, as opposed to the range of 77.1% to 89.2% obtainable in the south.^[8] Within the north-western zone, Kaduna State ranks second (69%) after Jigawa State (78.6%). Rural women are particularly disadvantaged when it comes to accessing and utilizing ANC services, as evidenced by a Nigerian study that concludes that the non-use of ANC was the most common among rural respondents from northern Nigeria.^[7] The determinants for ANC attendance in this study were almost similar in both study groups, with almost all demographic and socioeconomic factors (except age in the urban area; and age and parity in the rural area) being statistically significant [Table 3]. These findings are corroborated by other authors.^{[4],[5],[7],[14]}

Out of the 210 ANC attendees in this study, about 77.6% visited government-owned health facilities [Table 2]. The patronage of private hospitals was more prominent in urban areas (27.7%) relative to rural areas (10.1%). This is likely owing to the spatial (geographical) distribution of both public and private health facilities across the country, with urban areas being at an advantage.^[7],[15] Similarly, a Nepalese study in an urban area also reported 21% ANC uptake in private clinics.^[4] One urban respondent in this study attended ANC at a traditional birth attendant’s home [Table 2]. This is seemingly odd, in view of the apparently expected role of TBAs in the provision of maternal health care, by both nomenclature and the WHO definition (that a TBA is “a person who assists a mother during childbirth and who initially acquired their skills by attending births themselves or through an apprenticeship to other TBAs”).^[16] Thus, we could deduce that TBAs would be expected to feature at the stage of birth (delivery). However, this is not entirely out of place as the NDHS-2018 reports that about 1.2% of Nigerian ANC attendees patronize TBAs.^[8] Age was statistically significant in determining the choice of type of health facility attended for ANC among the rural women; whereas in the urban area, respondents’ level of education and parity as well as their husbands’ level of education and income were significant [Table 4].

Table 2: Antenatal Care Services Utilization among Respondents (n = 340)

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Table 3: Bivariate Analysis of Demographic and Socioeconomic Characteristics of Respondents and ANC Attendance (n = 340)

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Table 4: Bivariate Analysis of Demographic and Socioeconomic Characteristics of Respondents and Their Choice of ANC Facility/Location (n = 210)

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ANC was initiated in the first trimester by 149 (71%) of the 210 ANC attendees across both study areas [Table 2] in this study (rural 60.9%, urban 75.9%). These figures are far above the national estimates of 18.3% (rural 14.3%, urban 24.4%),^[8] which is very encouraging, in view of the often poor health indices reported in the northern part of the country. This improvement may be attributed to the subsidized maternal healthcare services obtainable in public health facilities in the state, which is reported to have a positive effect on ANC attendance.^[17] Most women in Nigeria and a number of other countries initiate ANC in the second trimester.^{[4],[5],[8],[13]} It is, however, recommended that women book for and begin ANC as soon as they discover they are pregnant.^{[4],[5],[12],[13]} This helps in the early assessment of pregnant women and the detection of any potential risks involved in the index pregnancy.^[4] It also informs and ensures the prompt institution of medical intervention(s) as well as in deciding and planning the best courses of action to be taken in advance, with regards to delivery and the postnatal period.^[1],[13] None of the variables were statistically significant in determining the time of initiation of ANC attendance among the rural women; however, for the urban women, their levels of education and parity, and their husbands’ levels of education and income were significant [Table 5]. Grand multiparas were not as likely to initiate ANC early relative to women of lower parity (1–3). This is consistent with findings from other studies, and it has been attributed to a sense of having experienced pregnancy (and delivery) many times earlier.^[4],[5],[12]

Table 5: Bivariate Analysis of Demographic and Socioeconomic Characteristics of Respondents and Time of ANC Booking (n = 210)

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The uptake of ANC is incomplete if the initial (booking) visit is not followed up by at least three (or more) additional visits, as recommended by the WHO.^{[1],[4],[5],[13],[14]} In this study, a total of 129 (61.4%) of the 210 ANC attendees (rural 56.5%, urban 63.8%) had four or more ANC visits [Table 2]. This finding is higher than the results of similar studies in south-eastern Nigeria and Bangladesh, which reported 43% (rural 37%, urban 50.8%) and 16% (rural 11.3%, urban 33.8%) ≥ 4 ANC visits, respectively.^[12],[13] A study in Nepal reported 87% ≥ 4 ANC visits; however, contrary to this study (which is community-based), this was facility-based.^[4] The NDHS-2018 reports a national figure of 56.8% for ≥ 4 ANC visits among Nigerian women (rural 45.7%, urban 73.7%).^[8] The determinants for a minimum of four ANC visits in this study were respondents’ income (for rural women) and tribe, level of education and parity of urban respondents as well as their husbands’ level of education [Table 6] and [Table 7].

Table 6: Bivariate Analysis of Demographic and Socioeconomic Characteristics of Rural Respondents and Number of ANC Visits (n = 69)

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Table 7: Bivariate Analysis of Demographic and Socioeconomic Characteristics of Urban Respondents and Number of ANC Visits (n = 141)

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With regards to the outcome of pregnancy, there were more live births among the urban women (93.5%) compared with the rural women (89.4%), although this difference was not statistically significant [Table 2]. In the rural area, respondents’ tribe and their husbands’ level of education and income were statistically significant determinants of pregnancy outcome; whereas respondents’ tribe and their level of education were significant among the urban women [Table 8]. A total of five (1.5%) stillbirths were reported across both study areas (n = 340). This corresponds with the national rate of about 1.7% stillbirths in Nigeria. This index is highest in the northern parts of the country, with the north-western zone (2.13%) coming second to the north-east (2.26%). It is lowest in the south-west (0.59%).^[8] The adequate and appropriate utilization of ANC is acclaimed to have a positive effect on pregnancy outcomes, as it is reported to contribute towards reducing perinatal mortalities (which includes stillbirths).^{[3],[4],[8],[12],[18]}

Table 8: Bivariate Analysis of Demographic and Socioeconomic Characteristics of Respondents and Pregnancy Outcome (n = 340)

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Strengths and limitations

This study concurrently and comparatively understudied patterns of ANC utilization among women in two distinct locations, as opposed to many similar studies that focus on either rural or urban areas. It also viewed ANC utilization from diverse angles beyond the mere assent of ANC attendance only, such as time of initiation of ANC (booking), type of facility attended, and total number of visits as well as pregnancy outcomes, which is the final hallmark of any obstetric experience. Furthermore, the factors influencing each of these aspects of ANC utilization were statistically determined for each women group (rural and urban). However, other relevant aspects of ANC utilization, such as the quality of care, were not addressed. These include perspectives such as the cadre and skill of health workers who superintended these ANC visits, the content of the services and the care received etc. Also, the factors that deterred the non-attendees of ANC among the respondents were not further explored. These gaps are acknowledged by the authors as limitations, which remain areas for further research.

Conclusion

This study demonstrated a consistent pattern of rural–urban disparities in diverse aspects of ANC utilization, with better indices among urban women relative to rural women. The determinants of ANC utilization predominantly bordered around literacy and income of the respondents and their husbands in both study areas, with more literate and affluent women and/ or their husbands being at an advantage. The findings in this study are not only consistent with those of other similar studies, but they also underscore the need to bridge the gap between rural and urban areas. Priority and urgent attention need to be given to matters such as the spatial (geographical) siting of health facilities; literacy of women, in particular, as well as their husbands; and financial issues such as addressing and reducing poverty levels and the cost of healthcare services, especially maternal and child health.

Financial support and sponsorship

Nil.

Conflict of interest

The authors declare no conflict of interest.

References

1.	World Health Organisation (WHO). WHO recommendations on antenatal care for a positive pregnancy experience. 2016. Available at: https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf.?sequence=1 (Accessed on the 7th of October, 2020)
2.	World Health Organisation (WHO). Maternal mortality. 2019. Available at: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality (Accessed on the 7th of October, 2020)
3.	Akombi BJ, Renzaho AM Perinatal mortality in sub-Saharan Africa: A meta-analysis of demographic and health surveys. Annals of Global Health 2019;85:106.
4.	Tuladhar H, Dhakal N Impact of antenatal care on maternal and perinatal outcome: A study at Nepal Medical College Teaching Hospital. Nepal Journal of Obstetrics and Gynaecology 2012;6:37-43.
5.	van Eijk AM, Bles HM, Odhiambo F, Ayisi JG, Blokland IE, Rosen DH, et al. Use of antenatal services and delivery care among women in rural western Kenya: A community based survey. Reprod Health 2006;3:2.
6.	United Nations Development Programme (UNDP) and the World Bank Group (WBG). Transitioning from the MDGs to the SDGs. United Nations. Department of Public Information - 2016 - United Nations Publications. Available at: https://www.undp.org/content/undp/en/home/librarypage/sustainable-development-goals/transitioning-from-the-mdgs-to-the-sdgs.html (Accessed on the 8th of October, 2020)
7.	Fagbamigbe AF, Idemudia ES Barriers to antenatal care use in nigeria: Evidences from non-users and implications for maternal health programming. BMC Pregnancy Childbirth 2015;15:95.
8.	National Population Commission (NPC) [Nigeria] and ICF. 2019. Nigeria Demographic and Health Survey 2018. Abuja, Nigeria and Rockville, MD: NPC and ICF.
9.	Akpan EO Early marriage in eastern Nigeria and the health consequences of vesico-vaginal fistulae (VVF) among young mothers. Gender and Development 2003;11:70-6.
10.	Nmadu GA, Avidime S, Oguntunde O, Dashe V, Abdulkarim B, Mandara M Girl child education: Rising to the challenge. African Journal of Reproductive Health 2010;14:107-12.
11.	Tsikata D Understanding and addressing inequalities in the context of structural transformation in Africa: A synthesis of seven country studies. Development 2015;58:206-29.
12.	Rahman M, Islam R, Islam AZ Rural-urban differentials of utilization of ante-natal health-care services in Bangladesh. Health Policy and Development 2008;6:117-25.
13.	Duru C, Eke NO, Ifeadike CO, Diwe KC, Uwakwe KA, Nwosu BO, Chineke HN Antenatal care services utilization among women of reproductive age in urban and rural communities of south east Nigeria: A comparative study. Afrimedic Journal 2014;5:50-8.
14.	Tiruaynet K, Muchie KF Determinants of utilization of antenatal care services in benishangul gumuz region, western Ethiopia: A study based on demographic and health survey. BMC Pregnancy Childbirth 2019;19:115.
15.	Nwakeze NM, Kandala NB The spatial distribution of health establishments in Nigeria. African Population Studies 2011;25:680-96.
16.	World Health Organisation (WHO). WHO recommendation on partnership with Traditional Birth Attendants (TBAs). 2015. Available at: https://extranet.who.int/rhl/topics/improving-health-system-performance/who-recommendation-partnership-traditional-birth-attendants-tbas (Accessed on the 14th of October, 2020)
17.	Kalu-Umeh NN, Sambo MN, Idris SH, Kurfi AM Costs and patterns of financing maternal health care services in rural communities in northern Nigeria: Evidence for designing national fee exemption policy. Int J MCH AIDS 2013;2: 163-72.
18.	Haftu A, Hagos H, Mehari MA, G/Her B Pregnant women adherence level to antenatal care visit and its effect on perinatal outcome among mothers in tigray public health institutions, 2017: Cohort study. BMC Res Notes 2018;11:872.