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DETERMINATION FACTORS INFLUENCING UTILIZATION OF ANTENATAL CARE SERVICES IN SELECTED HOSPITAL IN ILORIN WEST LOCAL GOVERNMENT AREA OF KWARA STATE

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EE/H2013/01430
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DECEMBER,2018

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DEDICATION
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TABLE OF CONTENT
COVER PAGE
APPROVAL PAGE
DEDICATION
ACKNOWLEDGEMENT
TABLE OF CONTENT

1. BACKGROUND TO THE STUDY

1.2 STATEMENT OF PROBLEM
1.3 JUSTIFICATION OF THE STUDY

1. SIGNIFICANCE OF THE STUDY

1.5 OBJECTIVE OF THE STUDY
1.5.1 GENERAL OBJECTIVES
1.5.2 SPECIFIC OBJECTIVES
1.6 RESEARCH QUESTIONS
1.7 RESEARCH HYPOTHESIS
1.8 SCOPE OF THE STUDY
1.9DEFINITION OF TERMS

CHAPTER TWO
2.0 INTRODUCTION
2.1 AN OVERVIEW ON ANTENATAL CARE
2.2OBJECTIVES OF ANTENATAL CARE

1. BENEFIT OF ANTENATAL CARE SERVICE
2. FACTORS INFLUENCING  UTILIZATION OF ANTENATAL CARE SERVICES

2.4.1GEOGRAPHICAL BARRIERS
2.4.2 ECONOMIC BARRIERS
2.4.3ANC PRACTICES AND DECISION MAKING INFLUENCES
2.4.4 SERVICE BARRIERS
2.6 KNOWLEDGE ABOUT ANTENATAL CARE SERVICES AND UTILIZATION OF ANC SERVICES
2.7 ACCESSIBILITY OF ANC SERVICES AND UTILIZATION OF ANC SERVICES
2.8 PERCEIVED QUALITY OF SERVICES RENDERED AND UTILIZATION OF ANC SERVICES
2.9PRACTICAL STEPS FOR STRENGTHENINGANTENATAL CARE
2.10 CONCEPTUAL FRAMEWORK
2.11 EMPIRICAL STUDIES
2.12 SUMMARY OF REVIEW

CHAPTER THREE

1. INTRODUCTION
1. RESEARCH DESIGN
2. RESEARCH SETTINGS

3.3 TARGET POPULATION
3.4 SAMPLING AND SAMPLING TECHNIQUES
3.5 SAMPLE SIZE DETERMINATION
3.6 RESEARCH INSTRUMENT
3.7VALIDATION AND RELIABILITY OF THE INSTRUMENT
3.7.1 VALIDITY OF THE INSTRUMENT
3.7.2 RELIABILITY OF THE INSTRUMENT
3.8. INCLUSION CRITERIA
3.9 EXCLUSION CRITERIA
3.10 PROCEDURES FOR DATA COLLECTION
3.11 ETHICAL CONSIDERATION

CHAPTER FOUR
4.1       PRESENTATION AND ANALYSIS OF DATA

CHAPTER FIVE
5.0 INTRODUCTION
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?
5.1.2 DOES ANC BENEFIT THE PREGNANT MOTHERS IN THE SELECTED HOSPITAL ILORIN WEST LOCAL GOVERNMENT AREA OF KWARA STATE?
5.1.3 DOES THE PERCEPTION OF QUALITY OF THE CARE SERVICES PROVIDED AFFECT THE UTILIZATION OF ANTENATAL CARE SERVICES IN SELECTED HOSPITAL?
5.1.4 WHAT ARE THE FACTORS THAT INFLUENCES THE UTILIZATION OF ANC?
5.2 SUMMARY OF FINDINGS
5.3 CONCLUSIONS
5.4 LIMITATION OF THE STUDY 

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].
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[3].
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 [16]. 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)[23], 33.9% of pregnant women in Nigeria had no contact with any ANC provider [15]. 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. 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[16].  

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

1. 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.
2. 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.
3. To determine the benefit of ANC service among pregnant women in Ilorin West Local Government Area of Kwara State
4. 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
5. To identify the factors influencing the utilization of ANC service
6. To recommend ways to improve the ANC service provided in the public hospital

1.6 Research questions

1. 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?
2. 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?
3. Does ANC benefit the pregnant mothers in the selected hospital Ilorin West Local Government Area of Kwara State?
4. Does the perception of quality of the care services provided affect the utilization of antenatal care services in selected hospital?
5. 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 womenin 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.

1.9Definition of terms
Utilization 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.
Knowledge 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.
Post-natal care: Is the care giving to the mother after delivery
Maternal mortality: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
Care givers: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.
Pregnancy: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.
Pre-eclampsia:A condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and proteinuria.

1.10                                      Project Organisation

This work is divided into five chapters including this introduction. Chapter two is on the literature review and method of data collection are in chapter three. Results of findings are discussed in chapter four. The way forward is and conclusion in chapter five.

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