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Wealth and antenatal care utilization in Nigeria:

Policy implications

Adeniyi Francis Fagbamigbe & Erhabor Sunday Idemudia

To cite this article: Adeniyi Francis Fagbamigbe & Erhabor Sunday Idemudia (2017) Wealth and
antenatal care utilization in Nigeria: Policy implications, Health Care for Women International, 38:1,
17-37, DOI: 10.1080/07399332.2016.1225743

To link to this article: https://doi.org/10.1080/07399332.2016.1225743

© 2017 The Author(s). Published by Taylor &

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Erhabor Sunday Idemudia

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Published online: 16 Sep 2016.

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HEALTH CARE FOR WOMEN INTERNATIONAL
2017, VOL. 38, NO. 1, 17–37
http://dx.doi.org/10.1080/07399332.2016.1225743

Wealth and antenatal care utilization in Nigeria: Policy

implications
Adeniyi Francis Fagbamigbea,b and Erhabor Sunday Idemudiaa
a
School of Research and Postgraduate Studies, Faculty of Human and Social Sciences, North West
University, Mafikeng, South Africa; bDepartment of Epidemiology and Medical Statistics, Faculty of Public
Health, College of Medicine, University of Ibadan, Ibadan, Nigeria

ABSTRACT ARTICLE HISTORY

Antenatal care (ANC) utilization is lower in Nigeria than the African Received 14 February 2015
average. We investigated the relationship between wealth and Accepted 15 August 2016
utilization of ANC and also assessed other determinants associated
with ANC utilization in Nigeria. Using data of the most recent
births within 5 years prior to a 2012 nationally representative
survey, we modeled predictors of ANC utilization. Respondents in
the wealthiest quintile were over five times (aOR D 5.5 (95% CI:
4.2–7.2) more likely to adequately use ANC. The odds of ANC use
were generally lower among the poor and the least educated
women living in rural areas who need ANC the most.

Undoubtedly, just like other sub-Saharan Africa countries, Nigeria is lagging behind in
antenatal care (ANC) utilization. Coincidentally, the sub-Saharan Africa region dis-
proportionately bears the burden of maternal death and ill health compared with the
developing countries. The 2014 World Health Organization (WHO) world health sta-
tistics (WHO, 2014) established that only 61% of pregnant women in Nigeria ever
made at least one contact with a skilled ANC provider and only 57% made the WHO
recommended “at least 4 visits” (WHO, 2002) between 2006 and 2013 despite free
ANC in most parts of Nigeria. In this study, we identified economic, cultural, societal,
and sociodemographic factors affecting ANC utilization in Nigeria so as to provide
evidence-based recommendations for policymakers.
Poor ANC utilization is an international public health challenge especially in the
developing countries. These countries accounted for 97% of the world population
growth, from 7.0 billion in 2011 to 7.04 billion in mid-2012 (Haub, 2012). There has
been reported a global rise in ANC utilization to about 70% between 1990 and 2013
and substantial progress achieved in most regions of the world, but increase in ANC

CONTACT Adeniyi Francis Fagbamigbe franstel74@yahoo.com School of Research and Postgraduate

Studies, Faculty of Human and Social Sciences, North West University, Mafikeng 2735, South Africa.
Color versions of one or more figures in this article are available online at www.tandfonline.com/uhcw.
© 2017 Adeniyi Francis Fagbamigbe and Erhabor Sunday Idemudia. Published with license by Taylor & Francis.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any
medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
18 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

utilization has been reportedly slow in sub-Saharan Africa (Lincetto, Mothebesoane-

anoh, Gomez, & Munjanja, 2010; WHO, 2014; World Bank, 2013b). Current ANC
utilization in Nigeria and the proportion having a minimum of four ANC visits rec-
ommended by WHO are below the world’s average despite having been declared as
the Africa’s largest economy. Is there any relationship between her large economy and
health dividend as far as ANC utilization is concerned?
ANC utilization plays a dual role in the attainment of the Millennium Develop-
ment Goals (MDGs) and the Sustainable Development Goals (SDGs). While it is
one of the indicators of the MDGs on improvement of maternal health, it also con-
tributes to some of the indicators of MDG on reduction of child mortality (Lincetto
et al., 2010; Office for the Coordination of Humanitarian Affairs [OCHA], 2015;
Population Reference Bureau, 2014; United Nations, 2013; World Bank, 2013a).
Poor utilization of ANC in Nigeria is a serious threat to the attainment of these
MDGs and SDGs in Nigeria and the world at large, although researchers have
reported that nonuse of skilled birth attendants contributes more to preventable
daily maternal deaths of nearly 800 women globally than nonuse of ANC (Lincetto
et al., 2010). Use of ANC could reduce this burden, of which 99% occur in develop-
ing countries (World Bank, 2013a, 2013b).
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 (WHO, 2014). This propor-
tion 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 (Fed-
eral Minstry of Health [FMoH], 2013; Gupta et al., 2014; National Population Commis-
sion (Nigeria) and ICF International, 2014; WHO, 2014). According to the 2013
Nigeria Demographic and Health Survey (NDHS), 33.9% of pregnant women in
Nigeria had no contact with any ANC provider (National Population Commission
[Nigeria] and ICF International, 2014). Wide disparities were found in the ANC utiliza-
tion 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%, and highest
in Osun state with 98.2% (National Population Commission [Nigeria] and ICF Interna-
tional, 2014).
To the federal government of Nigeria, at least four visits by a pregnant woman
to an ANC facility and birth delivery by a trained and skilled birth attendant is a
must (Ashir, Doctor, & Afenyadu, 2013; FMoH, 2004, 2013; National Population
Commission [Nigeria] and ICF International, 2014). The federal government has
also established primary health care facilities across the country to achieve this
purpose. These efforts have been complemented with state governments’ programs
aimed at ensuring that pregnant women have access to qualitative ANC (Babalola
& Fatusi, 2009; Doctor, Bairagi, Findley, & Helleringer, 2011; Fatusi, 2009). Despite
all these efforts, ANC utilization in Nigeria is abysmally low while the maternal
mortality rate (MMR) has remained very high.
 HEALTH CARE FOR WOMEN INTERNATIONAL 19

The maternal health situation in Nigeria is worrisome because it is far above the
African and global average. Compared with the world’s MMR estimates of 380,
300, and 210 and Africa’s estimates of 960, 820, and 500 in 1990, 2000 and 2012,
respectively, Nigeria mortality rates were 1200, 950, and 560 for the respective
years (WHO, 2014). These estimates have been corroborated by different local esti-
mates in Nigeria (Adebowale, Fagbamigbe, & Bamgboye, 2010; FMoH, 2013;
National Population Commission [Nigeria] and ICF International, 2014).
Several authors have attributed the high MMR in Nigeria to low utilization of
ANC services (Arthur, 2012; Ashir et al., 2013; Doctor et al., 2011; Ortiz, 2007).
This was further buttressed by a World Bank report that poor utilization of ANC
services results in high MMR and children deaths (World Bank, 2013a). High
MMR and high fertility, which are closely linked to high infant mortality and gen-
der inequality, are prevalent in many low-income countries. (World Bank, 2013b).
Researchers have unanimously recommended provision of adequate child and
maternal health services, such as ANC during pregnancy, as a means of ensuring
improvements in maternal health (Arthur, 2012; Ashir et al., 2013; Doctor et al.,
2011; Fagbamigbe, Akanbiemu, Adebowale, Manuwa-Olumide, & Korter, 2013;
Lincetto et al., 2010; Ortiz, 2007).
The main objective of ANC is to ensure optimal health outcomes for the mother
and her baby. Appropriate care during pregnancy is vital for the health of the
mother and the development of the unborn baby, promotion of healthy behaviors
and parenting skills, and provision of links between the woman and her family
with the formal health system. This has overreaching advantages including
increased likelihood of using a skilled attendant at birth and contribution to good
maternal health outcomes (Lincetto et al., 2010). ANC provided by a skilled ANC
provider enables early detection of complications and prompt treatment, preven-
tion of diseases through immunization and micronutrient supplementation, birth
preparedness and complication readiness, and health promotion and disease pre-
vention through health messages and counselling for pregnant women (Fatusi &
Ijadunola, 2003; National Population Commission [Nigeria] and ICF Interna-
tional, 2014; Osungbade, Shaahu, & Uchendu, 2011). Inadequate care during this
time breaks a critical link in the continuum of care, and it could have great conse-
quences on the health of both women and babies (Lincetto et al., 2010). Literature
is replete that ANC utilization could be influenced by wealth and other socioeco-
nomic and demographic indicators such as income, education, environment (rural
or urban), occupational status, and geopolitical region (Ajayi & Osakinle, 2013;
Ashir et al., 2013; Dairo & Owoyokun, 2010; Doctor et al., 2011; Doctor, Findley,
Afenyadu, Uzondu, & Ashir, 2013; Lincetto et al., 2010; Omo-Aghoja, Aisien,
Akuse, Bergstrom, & Okonofua, 2010; Osungbade, Oginni, & Olumide, 2008;
Osungbade et al., 2011).
Lateness in approaching ANC and misconception have also been identified in a
recent study as factors affecting utilization of ANC services (Onoh et al., 2012). It
has been reported in several studies that ANC utilization is lower among younger
20 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

women and those of low socioeconomic status (Arthur, 2012; Doctor et al., 2011;
Omo-Aghoja et al., 2010). Poor organization of ANC facilities in Nigeria might be
connected with the disparities in accessibility of the ANC services. It was empha-
sized in a previous study in Benin, Nigeria that maternity care in Nigeria is orga-
nized around three tiers: primary, secondary, and tertiary levels—with the
concentration of maternal health centers in urban than rural areas of the geopoliti-
cal zones (Omo-Aghoja et al., 2010). This could be responsible for higher use in
urban areas than in rural areas in Nigeria.
In recent years, ANC has been made free in certain parts of Nigeria and was
reported to have contributed to ANC utilization in those areas. For instance, the
over 95% ANC utilization found among nursing mothers and pregnant women in
some selected rural and semi-urban communities in Okitipupa Local Government
Area (LGA), Ondo State, South Western Nigeria, in 2009 was attributed to the
recently introduced free ANC services in the state (Akanbiemu, Olumide, Fagba-
migbe, & Adebowale, 2013). With the high level of poverty in the country, financial
cost could pose barriers to the use of ANC services by some women, particularly
the most vulnerable—the “poorest of the poor” (Fagbamigbe & Idemudia, 2015).
Globally, the economic growth of a country has been assessed using its health out-
comes; also increased national wealth has been related to improved health (Fagbamigbe
et al., 2015). Health is central to overall well-being and wealth (Arthur, 2012). Accord-
ing to Smith, 1999, people’s health and wealth status are closely related, and this rela-
tionship is bidirectional (Smith, 1999). A previously financially buoyant individual may
become poor as a result of ill health; similarly, poor health may arise from being poor if
an individual is unable to afford adequate basic necessities such as sanitation, health
care, food, and housing (Arthur, 2012; Balen et al., 2010; Fagbamigbe et al., 2015).
While unavailability and inaccessibility of health facilities are health utilization prob-
lems to be dealt with by various governments in less-developed countries, on an indi-
vidual level, poverty may limit use of quality health care service especially among
women in their reproductive period. Poverty exists when people lack basics needs to
improve their standard of living (United Nations, 2013).
Health and wealth strengthen each other with health systems as the catalyst
(Figueras, McKee, Lessof, Duran, & Menabde, 2012). While it is on record that
healthier people are more productive and can therefore generate wealth, a rather
financially disadvantaged individual may be unable to access health services and
become more impoverished (Figueras et al., 2012; Smith, 1999; Suhrcke et al.,
2006). A poverty-related lifestyle would ultimately reduce access to and utilization
of health facilities and services (Adler et al., 1994; Arthur, 2012; Balen et al., 2010;
Fagbamigbe et al., 2015; Krieger, 2001; McDonough, Sacker, & Wiggins, 2005).
This has constituted health inequalities in most parts of the world, especially in
less-developed countries. It has allowed better-off individuals to benefit from life-
style changes and improved health care, while the poorer ones are left unattended.
Health and wealth cannot be disconnected from a functional health system. Fig-
ueras and colleagues (2012) established a complex, dynamic, and triangular
 HEALTH CARE FOR WOMEN INTERNATIONAL 21

relationship among health systems, health, and wealth. They showed that the three
elements impact collectively on societal well-being. This is evident from the fact
that societies draw satisfaction from the existence of health services and the ability
of people to access them (Figueras et al., 2012). Furthermore, wealth may be neces-
sary to access health in the absence of a functional health system. Some previous
studies have linked ANC utilization to wealth and other factors including educa-
tion, residence, employment, and spousal support (Arthur, 2012; Fagbamigbe &
Idemudia, 2015; Fagbamigbe et al., 2015; Gage, 2007). Fagbamigbe and colleagues
reported that financial hindrances were cited by about two-fifths of women not
attending ANC services in Nigeria (Fagbamigbe & Idemudia, 2015).
It was reported in a recent Ghanaian study that the wealth status of individuals
hinders ANC utilization even though maternal health care services are rendered
free of charge in Ghana (Arthur, 2012). Similarly, it was reported in an Indonesian
study that a percentage attributable risk of 55% of the total risks for underutilizing
ANC services was due to combined low household wealth index and low maternal
education level (Titaley, Dibley, & Roberts, 2010). Hidden costs such as transporta-
tion and opportunity costs of spending a long time travelling and waiting at health
facilities may seriously affect the usage and the adequacy of usage. Some previous
studies in Nigeria, however, reported that neither the income of respondents nor
the income of their spouses was significant to ANC utilization (Dairo & Owoyo-
kun, 2010; Nwosu, Urama, & Uruakpa, 2012).
Despite the established strong association between ANC utilization and infant
and MMR, the proportion of women attending ANC services has remained very
low in sub-Saharan Africa and in other less-developed countries—the huge global
campaign targeted at promoting high ANC utilization notwithstanding (Ajayi &
Osakinle, 2013; Ashir et al., 2013; Lincetto et al., 2010).
The burning questions are what is responsible for the low ANC utilization in
Nigeria? Does wealth status of women play any role in ANC utilization in Nigeria?
Are there geographical variations in ANC utilization in Nigeria with respect to
wealth status? Are there any other influencing factors? Has the newly introduced
“Free ANC regime” in certain parts of Nigeria influenced the role of individual
wealth in ANC utilization in Nigeria? To answer these questions, we investigated
the impact of women’s wealth status and associated factors on ANC utilization in
Nigeria. We focussed on both utilization and adequacy of number of ANC visits.
With the use of a large nationally representative data in this study, we identified
the determinants of ANC utilization and adequacy of number of ANC visits.
Amongst others, this study bridged the gap and conflicting positions of previous
studies on association between wealth and ANC utilization in Nigeria. More
importantly, the current study evaluated and updated the body of knowledge on
the impact of the widely introduced free child and maternal health care policy on
ANC utilization in Nigeria as well as the critical roles played by individual wealth
on ANC utilization in Nigeria. We documented hindrances to ANC utilization in
Nigeria and made evidence-based recommendations to policymakers. Besides
22 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

influencing ANC programming and policy in Nigeria, the outcomes of this study
would provide the basis for sharing the Nigerian ANC experience with other coun-
tries having similar ANC utilization so as to inform local and global maternal care
policy and planning.

Methods
Theoretical framework
Identifying the significant determinants of health care utilization can be very chal-
lenging (Andersen, 1995). This due to the fact that factors influencing choice to
seek health care and which provider to use are very diverse; they include knowl-
edge, perceptions, demographics, health belief, culture, economics, access, belief in
efficacy, as well as the social context. To facilitate a detailed understanding of
health care utilization complexities, several theories and models of health care utili-
zation have been developed. Suchman developed stages of illness and medical care
theory (Suchman, 1965) while Mechanic proposed general theory of help seeking
(Mechanic, 1978), and Parsons developed sick role theory (Parsons, 1951). Other
models include Young’s choice-making model (Young & Young-Garro, 1982),
Rosenstock’s health belief model (Rosenstock, Strecher, & Becker, 1994), and
Andersen’s health behavior model (Andersen, 1995). These theories and models
were aimed at understanding the need for and identification of key factors influ-
encing the sources of variability in health care utilization.
In this study, we adopted the health care utilization model developed by Ander-
sen. The model was in phases. Phase 1 of the model, which dealt with behavioral
changes, categorized the determinants of health care utilization into three broad
categories of characteristics: (a) the predisposing characteristics (demographics,
the social structure, and health beliefs), (b) enabling characteristics (resources
found within families and communities), and (c) need-based characteristics (indi-
vidual, social, or clinically evaluated perception of need for health services (Ander-
sen, 1968; Wolinsky, 1988). This behavioral model has been used in earlier studies
(Fagbamigbe, Akinyemi, Adedokun, & Bamgboye, 2011).
In phase 2, the health care system, which consists of health policy, resour-
ces, and organization, was included. It had emphasized that resource manage-
ment, volume, and distribution of labor, capital, equipment, and qualification
of health care personnel as well as the changes in these over time ultimately
influences access to and use of health services. The model stressed that use of
health care is a reflection of customer satisfaction, which is a function of con-
venience, quality, availability, financing, and types and levels of health care
providers (Aday & Andersen, 1974).
The third phase incorporated health outcomes (perceived and evaluated
health status and consumer satisfaction) in addition to existing primary deter-
minants (characteristics of the population, the health care system, and the
external environment) and health behaviors (personal health practices and use
 HEALTH CARE FOR WOMEN INTERNATIONAL 23

Figure 1. An emerging model of health care utilization—Phase 4. Source: Anderson (1995).

of health services) which are the direct cause of health outcomes. This inclu-
sion allowed the model to be extended to the measures of access to include
dimensions that are particularly necessary for health policy and reforms
(Andersen, Davidson, & Ganz, 1994).
The fourth phase, described as the “emerging model” in 1995, emphasized
the dynamic and recurrence nature of health services use. This includes health
status outcomes. The emerging model portrays the multiple influences on
health services use and subsequently on health status and incorporated a feed-
back loop showing that the outcome in turn has an effect on subsequent pre-
disposing factors, perceived need, and health behavior as shown in Figure 1
(Andersen, 1995).
Constrained by the nature and numbers of factors covered in the secondary
data used in our study, we leveraged on the Anderson model to identify deter-
minants of ANC utilization in Nigeria. Specifically, we identified how wealth
and other predisposing characteristics and enabling resources affect ANC
utilization.

Data sources
Data from the 2012 National HIV/AIDS and Reproductive Health and Serological
Survey (NARHS Plus), a cross-sectional study, was used in this study. The data is a
nationally representative sample of females aged 15–49 years and males aged 15–
64 years living in households in rural and urban areas in Nigeria. The households
were drawn from the updated master sample frame of rural and urban localities and
Enumeration Areas (EAs) in all the 36 states and the Federal Capital Territory
(FCT) as developed and maintained by the Nigeria National Population Commis-
sion (NPC).
24 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

Sampling
Multistage cluster sampling was used to select eligible persons. Stage 1 involved the
selection of rural and urban localities from each state and FCT. In stage 2, EAs within
the selected rural and urban localities were selected. At stage 3, the households were
listed and selected, while stage 4 involved selection of individual respondents from the
households for interview. Thirty-two individuals were sampled from each of the 30
sampled EA (clusters) from each state. Overall, 35,520 individual respondents were
selected for final interview, of which 31,235 individuals (88%) were successfully inter-
viewed. Other details of sampling methodology have been reported (FMoH, 2013).

Ethical considerations
The survey instruments and materials were presented for ethical clearance at the
Institutional Review Board (IRB) of the National Institute of Medical Research
prior to the commencement of the survey. Oral and written informed consent was
sought from each respondent before a questionnaire was administered. Respond-
ents were adequately informed of the survey objectives upon which an individual
has the right to participate or otherwise. Details of the ethical approvals have been
reported earlier (FMoH, 2013).

Data
Of the 15,567 women interviewed in the 2012 NARHS, only 6,299 reported to have
had at least one child within 5 years preceding the survey. All analyses in this
study, therefore, were based on these 6,299 female respondents.

Dependent variable
The outcomes of interest in this study are ANC utilization and the adequacy of
number of ANC visits. Those who attended ANC stated the number of times they
visited “qualified” ANC providers. Women who had four or more ANC visits in
the course of a pregnancy as recommended by the WHO (2002) were classified as
having had an adequate number of ANC visits.

Independent variables
The independent variables in this study are wealth status, categorized into poorest,
poorer, average, wealthier, and wealthiest; educational attainment, categorized into no
formal education, Quranic, primary, secondary, and higher; marital status, categorized
into never married, formerly married, and currently married; location of residence, cat-
egorized into rural and urban settings, categorized into geopolitical zones, categorized
into North Central, North East, North West, South East, South South, and South West;
age of respondent at birth, categorized into <20, 20–24, 25–34 and 35–49 years; tribe,
categorized into Hausa, Yoruba, Igbo, and others; religion, categorized into Islam,
 HEALTH CARE FOR WOMEN INTERNATIONAL 25

Christianity, and other; birth order, categorized into 1, 2, 3, or 4C; employment status,
categorized into currently employed and unemployed; and some behavioral factors, cat-
egorized into need for spouse permission to visit ANC provider: yes/no; having prob-
lem with money: yes/no; and whether distance from health facility is a problem: yes/no.
These variables have been associated with ANC utilization in previous studies (Arthur,
2012; Dairo & Owoyokun, 2010; Fagbamigbe & Idemudia, 2015; Fagbamigbe et al.,
2015; Gage, 2007; Glei, Goldman, & Rodriguez, 2003; Gymiah, Takyi, & Addai, 2006;
Joshi, Torvaldsen, Hodgson, & Hayen, 2014; Kyei, Campbell, & Gabrysch, 2012).

Statistical analyses
We used descriptive statistics to determine the distribution of the respondents’
sociodemographic and behavioral characteristics as well as ANC utilization. Bivari-
ate analyses were carried out to establish a significant relationship among ANC uti-
lization, adequacy of number of ANC visits, and the independent variables using
Pearson chi-square (X2) test of association. We used logistic regression to model
relationship between the dependent and independent variables at the bivariate
level. The dependent variables were modelled using significant variables from
bivariate analysis and were adjusted for in multiple logistic regression models.
Logistic regression model of the form,
P.yi /
f .yi / D ln D b0 C b1 xi1 C
C bk xik ; (1)
1 ¡ P.yi /

determines the association between a dichotomic dependent variable and indepen-

dent variables by converting the dependent variable to probability scores taking on
values between zero and one:

eb0 C b1 xi1 C
C bk xik 1

P.yi / D b C b C
C b
D ; (2)
1 C e 0 1 i1 x x
k ik 1 C e 0 b1 xi1 C
C bk xik /
¡ .b C

where yi is the category of the dependent variable for the ith observation and xij is
the jth independent variable (j D 1,2,…k) for that observation, bj is the jth coeffi-
cient of xij and indicates its effect on the fitted model.
We engaged the Hosmer and Lemeshow statistic (Hosmer & Lemeshow, 1989)
to test the goodness-of-fit of the models and also Omnibus tests of model coeffi-
cients to test whether the explained variance in a set of data is significantly greater
than the unexplained variance as described in an earlier study (Preacher, Curran,
& Bauer, 2006). The omnibus test relates to the hypotheses H0: b1 D b2 D …. D bk
vs H1: at least one pair bj6¼ bi. All tests were carried out at 5% significance level.
Any model with p value greater than .05 was considered significant. While data
were weighted to reflect differences in population sizes of each state in Nigeria, the
intracluster correlation coefficient was minimized by the use of effective sample
size and use of complex survey data analysis mechanism in STATA 12.
26 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

Results
Descriptive analysis
In all, 6,299 women reported to have given birth within 5 years (2007–2012) pre-
ceding the survey. The mean age of the respondents was 29.3 § 7.3 years. ANC
utilization was 65.1%, while 56.2% had adequate numbers of ANC visits. There
was a rise in ANC utilization with increased wealth status, from 38.3% among
women in the poorest wealth quintile to 92.0% among women in the highest
wealth quintile. About 82% of the respondents in urban areas reported visiting
an ANC facility at least once compared with 56.7% among rural respondents. As
shown in Table 1 and Figure 2, ANC usage of 54.2% was found among respond-
ents who needed their husband’s permission to seek ANC compared with 67.4%
among those who don’t need it.
On the adequacy of number of ANC visits, only 31.4% of respondents without
any formal education visited an ANC provider four or more times; the proportion
was 88.1% among their counterparts who had higher education. Considering the
Pearson chi square test used to test significance of association between the explana-
tory variables and use of ANC and the adequacy of number of ANC visits, all fac-
tors considered, except employment and marital status, were statistically
significant.

Bivariate logistic regression

On the bivariate logistic regression models between ANC utilization and the
independent variables, respondents in the wealthiest quintile were about 18 times
(OR D 18.3 (95% CI: 14.5–23.3)) more likely to have at least one contact with an

Figure 2. Distribution of ANC (antenatal care) use and adequacy of use by selected respondents’
characteristics.
 HEALTH CARE FOR WOMEN INTERNATIONAL 27

Table 1. Characteristics of the respondents and distribution of ANC use and adequacy of number of
ANC visits.
Adequacy of number of ANC
ANC coverage (1 visit) visits ( 4 visits)

Variables n (%) Used ANC p value Adequate p value

Wealth quintile Poorest 1495 (23.7) 38.3 <.0001 27.1 <.0001

Poorer 1359 (21.6) 51.8 42.6
Average 1166 (18.5) 72.8 62.3
Wealthier 1127 (17.9) 81.5 74.4
Wealthiest 1150 (18.3) 92.0 86.2
Residence Urban 2112 (33.5) 81.8 <.0001 75.3 <.0001
Rural 4187 (66.5) 56.7 46.5
Education No formal 2105 (33.4) 40.3 <.0001 31.4 <.0001
Qur’anic only 523 (8.3) 56.4 44.9
Primary 1126 (17.9) 71.0 60.2
Secondary 2020 (32.1) 83.1 74.5
Higher 521 (8.3) 91.6 88.1
Marital status CM//LWSP 5883 (93.9) 65.6 .029 56.5 .126
Formerly married 221 (3.5) 57.0 49.1
Never married 159 (2.5) 63.5 56.3
Age at birth <20 371 (5.9) 50.4 <.0001 38.3 <.0001
20–24 1228 (19.5) 60.8 49.3
25–34 3091 (49.1) 69.8 60.9
35–49 1610 (25.6) 62.8 56.4
Zone North Central 936 (14.9) 66 <.0001 51.8 <.0001
North East 773 (12.3) 50.7 38.8
North West 1797 (28.5) 48.5 39.4
South East 537 (8.5) 85.7 79.1
South South 899 (14.3) 69.2 61.4
South West 1358 (21.6) 83.8 78.8
Birth order 1 1174 (19) 69.9 <.0001 60.4 <.0001
2 1178 (19) 66.5 58.3
3 1068 (17.3) 68.8 59.7
4C 2772 (44.8) 61.7 52.7
Ethnicity Hausa/Fulani 2147 (34.1) 48.2 <.0001 38.5 <.0001
Igbo 761 (12.1) 86.7 80.9
Yoruba 1192 (18.9) 84.6 78.7
Others 2199 (34.9) 63.6 52.7
Religion Islam 3241 (51.4) 55.6 <.0001 46.3 <.0001
Christian 2995 (47.6) 75.9 67.5
Others 63 (1.0) 41.3 28.6
Employment Employed 6044 (95.9) 64.9 .095 56 .095
Unemployed 256 (4.1) 70.0 60.9
Need spouse permission Yes 1045 (16.8) 54.2 <.0001 44.4 <.0001
No 5190 (83.2) 67.4 58.6
No enough money Yes 3058 (49.1) 60.0 <.0001 49.9 <.0001
No 3176 (50.9) 70.2 62.3
Distance is a problem Yes 2258 (36.2) 53.1 <.0001 42.7 <.0001
No 3977 (63.8) 72.0 63.9
Total 6234 (100) 65.2 56.2

Note: CM/LWSP: currently married or living with a sexual partner.


Significant at 5% significance level.

ANC provider than respondents in the poorest wealth quintile. As shown in

Table 2, respondents with higher education were about 16 times (OR D 16.2
(95% CI: 11.7–22.4)) more likely to have approached an ANC provider than a
respondent without a formal education. On the adequacy of the number of ANC
visits made, respondents in the wealthiest wealth quintile were almost 17 times
28 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

Table 2. Independent determinants of ANC utilization and adequacy of number of ANC visits.
Adequacy of number
ANC coverage (at least 1 visit) of ANC visits ( 4)

Variables OR 95% CI p value OR 95% CI p value

Wealth quintile Poorest Ref 1.0

Poorer 1.7 1.5–2.0 <.0001 2.0 1.7–2.3 <.0001
Average 4.3 3.6–5.1 <.0001 4.4 3.8–5.2 <.0001
Wealthier 7.0 5.9–8.4 <.0001 7.8 6.6–9.3 <.0001
Wealthiest 18.4 14.5–23 <.0001 16.9 13.8–20 <.0001
Residence Urban 3.4 3.0–3.9 <.0001 3.5 3.1–4.0 <.0001
Rural Ref
Education No formal Ref
Qur’anic only 1.9 1.6–2.3 <.0001 1.8 1.5–2.2 <.0001
Primary 3.6 3.1–4.2 <.0001 3.3 2.8–3.8 <.0001
Secondary 7.3 6.3–8.4 <.0001 6.4 5.5–7.3 <.0001
Higher 16.2 11.7–22 <.0001 16.2 12.2–22 <.0001
Marital status CM/LWSP 1.1 0.8–1.5 .632 1.0 0.7–1.4 .984
Formerly married 0.8 0.5–1.1 .177 0.7 0.5–1.1 .140
Never married Ref
Age (years) <20 Ref
20–24 1.5 1.2–1.9 <.0001 1.6 1.2–2.0 <.0001
25–34 2.3 1.8–2.8 <.0001 2.5 2.0–3.1 <.0001
35–49 1.7 1.3–2.1 <.0001 2.1 1.7–2.6 <.0001
Zone North Central Ref
North East 0.5 0.4–0.6 <.0001 0.6 0.5–0.7 <.0001
North West 0.5 0.4–0.6 <.0001 0.6 0.5–0.7 <.0001
South East 3.1 2.3–4.1 <.0001 3.5 2.8–4.5 <.0001
South South 1.2 1.0–1.4 .139 1.5 1.2–1.8 <.0001
South West 2.7 2.2–3.3 <.0001 3.5 2.9–4.2 <.0001
Birth order 1 1.4 1.2–1.7 <.0001 1.4 1.2–1.6 <.0001
2 1.2 1.1–1.4 .005 1.3 1.1–1.4 .001
3 1.4 1.2–1.6 <.0001 1.3 1.2–1.5 <.0001
4C Ref
Ethnicity Hausa/Fulani Ref
Igbo 7.1 5.6–8.9 <.0001 6.7 5.5–8.2 <.0001
Yoruba 5.9 5.0–7.1 <.0001 5.9 5.0–6.9 <.0001
Others 1.9 1.7–2.1 <.0001 1.8 1.6–2.0 <.0001
Religion Islam Ref
Christian 2.5 2.2–2.8 <.0001 2.4 2.2–2.7 <.0001
Others 0.6 0.3–0.9 .023 0.5 0.3–0.8 .006 
Employment Employed Ref
Unemployed 1.3 1.0–1.7 .093 1.2 1.0–1.6 .108
Need spouse permission Yes Ref

No 1.8 1.5–2.0 <.0001 1.8 1.5–2.0 <.0001
No enough money Yes Ref
No 1.6 1.4–1.7 <.0001 1.7 1.5–1.8 <.0001
Distance is a problem Yes Ref
No 2.3 2.0–2.5 <.0001 2.4 2.1–2.6 <.0001

Note: ANC: antenatal care; CI: confidence interval; CM/LWSP: currently married or living with a sexual partner; OR:
means odds ratio; Ref: reference category.

Significant at 5% significance level.

(OR D 16.9 (95% CI: 13.8–20.7)) more likely to pay four or more visits to an
ANC provider than those in the poorest category.

Multiple logistic regression

Table 3 shows the models developed for ANC utilization and adequacy of number
of ANC visits. In model 1, we controlled for the sociodemographic variables and
Table 3. Adjusted determinants of ANC utilization and adequacy of number of ANC visits.
Adequacy of number of ANC visits
ANC utilization (at least 1 visit) ( 4 visits)

Model 1 Model 2 Model 1 Model 2

Variable AOR(95% CI) p value AOR(95% CI) p value AOR(95% CI) p value AOR(95% CI) p value

Wealth quintile Poorest Ref

Poorer 1.5(1.3–1.8) <.0001 1.5(1.3–1.7) <.0001 1.7(1.4–2.0) <.0001 1.7(1.4–2.0) <.0001
Average 2.8(2.3–3.4) <.0001 2.7(2.2–3.3) <.0001 2.7(2.3–3.3) <.0001 2.7(2.2–3.2) <.0001
Wealthier 3.3(2.6–4.2) <.0001 3.1(2.5–4.0) <.0001 3.5(2.8–4.4) <.0001 3.3(2.7–4.2) <.0001
Wealthiest 7.0(5.2–9.5) <.0001 6.7(4.9–9.1) <.0001 5.9(4.5–7.7) <.0001 5.5(4.2–7.2) <.0001
Residence Urban 1.1(0.9–1.3) .466 1.1(0.9–1.3) .541 1.1(1.0–1.3) .122 1.1(1.0–1.3) .167
Rural Ref
Education No formal Ref
Qur’anic only 1.8(1.5–2.3) <.0001 1.8(1.5–2.3) <.0001 1.7(1.4–2.1) <.0001 1.7(1.4–2.1) <.0001
Primary 2.4(2.0–2.8) <.0001 2.3(1.9–2.8) <.0001 2.0(1.7–2.4) <.0001 1.9(1.6–2.3) <.0001
Secondary 3.3(2.7–4.0) <.0001 3.2(2.6–4.0) <.0001 2.6(2.2–3.2) <.0001 2.6(2.1–3.1) <.0001
Higher 4.6(3.1–6.8) <.0001 4.8(3.2–7.0) <.0001 4.4(3.2–6.2) <.0001 4.6(3.2–6.4) <.0001
Age at birth <20 Ref
20–24 1.0(0.8–1.3) .953 1.0(0.8–1.3) .926 1.1(0.8–1.4) .605 1.1(0.8–1.4) .607
25–34 1.1(0.9–1.5) .329 1.1(0.9–1.5) .406 1.3(1.0–1.7) .060 1.3(1.0–1.7) .084
35–49 0.7(0.6–1.0) .057 0.7(0.5–1.0) .037 1.0(0.7–1.3) .992 1.0(0.7–1.3) .809
Zone North Central Ref
North East 0.9(0.7–1.1) .345 0.9(0.7–1.2) .516 1.0(0.8–1.3) .841 1.1(0.8–1.3) .650
North West 0.8(0.6–1.0) .049 0.8(0.6–1.0) .048 1.0(0.8–1.3) .900 1.0(0.8–1.3) .966
South East 1.0(0.6–1.6) .850 0.9(0.6–1.6) .825 1.3(0.8–2.0) .302 1.2(0.8–1.9) .358
South South 0.5(0.4–0.6) <.0001 0.5(0.4–0.6) <.0001 0.8(0.6–0.9) .014 0.7(0.6–0.9) .008
South West 1.0(0.7–1.4) .932 1.0(0.7–1.3) .912 1.6(1.2–2.0) .001 1.5(1.1–2.0) .004
Birth order 1 Ref
2 0.8(0.7–1.0) .087 0.8(0.7–1.0) .094 0.9(0.7–1.1) .279 0.9(0.7–1.1) .333
3 0.9(0.8–1.2) .582 0.9(0.8–1.2) .609 0.9(0.7–1.1) .426 0.9(0.8–1.2) .504
4C 1.1(0.9–1.4) .257 1.1(0.9–1.4) .196 1.1(0.9–1.3) .360 1.1(0.9–1.4) .244
HEALTH CARE FOR WOMEN INTERNATIONAL

(Continued on next page)

29
 30

Table 3. (Continued)
Adequacy of number of ANC visits
ANC utilization (at least 1 visit) ( 4 visits)

Model 1 Model 2 Model 1 Model 2

Variable AOR(95% CI) p value AOR(95% CI) p value AOR(95% CI) p value AOR(95% CI) p value

Ethnicity Hausa/Fulani Ref

A. F. FAGBAMIGBE AND E. S. IDEMUDIA

Igbo 2.0(1.2–3.2) .007 1.8(1.1–3.0) .014 2.1(1.3–3.2) .001 2.0(1.3–3) .002

Yoruba 1.2(0.9–1.8) .239 1.3(0.9–1.8) .215 1.2(0.9–1.7) .255 1.2(0.9–1.7) .202
Others 1.1(0.9–1.4) .385 1.1(0.8–1.3) .588 1.2(0.9–1.5) .150 1.1(0.9–1.4) .244
Religion Islam Ref
Christian 1.0(0.8–1.3) .771 1.0(0.9–1.3) .689 0.9(0.8–1.1) .579 1.0(0.8–1.2) .744
Others 0.4(0.2–0.7) .003 0.4(0.2–0.8) .006 0.3(0.2–0.6) <.0001 0.3(0.2–0.6) <.0001
Need spouse permission Yes Ref
No 1.1(1.0–1.3) .159 1.1(0.9–1.3) .184
No enough money Yes Ref
No 0.8(0.7–0.9) .002 0.8(0.7–0.9) .006
Distance is a problem Yes Ref)
No 1.5(1.3–1.7) <.0001 1.5(1.3–1.7) <.0001

Note: ANC: antenatal care; CI: confidence interval; CM/LWSP: currently married or living with a sexual partner; OR: odd ratio; Ref: Reference category.

Significant at 5% significance level.
 HEALTH CARE FOR WOMEN INTERNATIONAL 31

found it to be unfit for the data by the Hosmer and Lemeshow statistic (p D .03).
Model 2, in which we controlled for all variables considered in model 1 in addition
to other behavioral factors, was found appropriate (p D .42) by the Hosmer and
Lemeshow test as well as the Omnibus tests of model coefficients. Controlling for
all other variables in the model, we found that respondents from wealthiest wealth
quintiles were only 6.7 times (aOR D 6.7 (95% CI: 4.9–9.1) more likely to have vis-
ited an ANC provider at least once. Based the adequacy of the number of visits
made, both models fitted were found appropriate by the Omnibus test and the
Hosmer and Lemeshow statistics (p D .52). While controlling for other variables,
respondents in the wealthiest wealth quintile were 5.5 times (aOR D 5.5 (95% CI:
4.2–7.2) more likely to have paid an adequate number of visits to the ANC pro-
viders. Respondents who did not need spouse’s permission were not significantly
more likely to have visited ANC providers four times or more.

Discussion
In this study, we determined the effect of wealth and other socioeconomic and
behavioral factors on ANC utilization in Nigeria. We also investigated differentials
in adequacy of number of ANC visits and factors influencing it. While the ANC
utilization in Nigeria remained below the African and the global average, there
were geographical variations in the ANC utilization within Nigeria. Offering free
ANC may be insufficient in improving ANC utilization because there are other sig-
nificant demographic, societal, and cultural factors such as economic status, resi-
dence, decision making, educational opportunities, and transportation that could
impact women’s health and accessibility to maternal health services.
Wealth status was found to be the strongest determinant of ANC utilization and
adequacy of number of ANC visits in Nigeria. The respondents in the wealthiest
quintile had a higher likelihood of ANC utilization and adequate ANC visits than
the respondents in the poorest wealth quintile. The chances of using ANC increase
as the respondents become wealthier. We found that women who had problems
with getting money to access ANC had lower ANC usage than others who did not
have financial limitations. This finding is consistent with outcomes of studies else-
where (Ajayi & Osakinle, 2013; Arthur, 2012; Chandhiok, Dhillon, Kambo, & Sax-
ena, 2006; Eghieye, 2014; Fagbamigbe & Idemudia, 2015; Ibeh, 2008; Ortiz, 2007;
Roy, Mohan, Singh, Singh, & Srivastava, 2013; Titaley et al., 2010) but at variance
with findings of a Nigeria study (Dairo & Owoyokun, 2010). The finding was fur-
ther corroborated by recent reports that some countries, Nigeria inclusive, may
operate below the poverty line for some years to come, a phenomenon that could
affect the countries’ chances of providing quality health care for their citizenry
(Lincetto et al., 2010; United Nations, 2013). The authors had noted that these
countries are paying more to finance their debt than they are spending on health
and education. This has hitherto limited their abilities to break the poverty cycle.
This has prevented women in these poverty-stricken countries from accessing
32 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

ANC services optimally. Empowering Nigerian women through adequate educa-

tion and employment should be paramount in policies targeted at improving ANC
utilization. This will eliminate inequalities in health care delivery in Nigeria.
We also found educational attainment to have impacted on ANC utilization and
the adequacy of number of ANC visits in Nigeria. Women with higher education
were more likely to access ANC services than respondents with no formal educa-
tion. ANC use had increased substantially with educational achievements as previ-
ously documented (Arthur, 2012; Titaley et al., 2010). Improving the education of
the female children as they progress into womanhood will contribute greatly to the
utilization of ANC services and thus help in combatting maternal and child mor-
tality (Arthur, 2012; Ortiz, 2007; Titaley et al., 2010). Researchers have reported
positive correlation between wealth and education (Doctor et al., 2011; Fagbamigbe
et al., 2015; United Nations, 2013). Although some uneducated women may get
married to wealthier men and thereby attain better socioeconomic status, the
majority of women with either no formal or low education in Nigeria belong to the
lowest level of wealth quintiles (FMoH, 2013). There is urgent need to empower
women using timely, qualitative, and appropriate education as a tool. Ensuring
that mothers in Nigeria receive better education will increase utilization of mater-
nal and ANC services, which would in turn reduce maternal and child mortality.
Going by outcomes of our study, we suggest that policies should be put place to
encourage women to have up to secondary education, if remarkable improvements
are expected in ANC utilization in Nigeria.
We found residence and geographical zones where women live to be signifi-
cantly associated with ANC utilization. This was higher among pregnant women
from South West and South East Nigeria compared with pregnant women from
the Northern part of the country. Our finding was at consonance with the conclu-
sions drawn in a Northern Nigerian study that the North still lag behind South
Nigeria in terms of availability and use of maternal health services (Doctor et al.,
2011). We also found that pregnant women in urban areas used ANC more than
their counterparts in the rural areas as documented previously elsewhere (Gage,
2007; Ortiz, 2007; Overbosch, 2004). This could be attributed to a higher number
of health facilities in urban than rural areas and also because economically advan-
taged people live in urban rather than rural areas. Government should formulate
policies that will create awareness and educate and promote ANC services among
women and the communities in all regions, especially among those with lower
ANC utilization.
Distances to health facilities was also found to be significant with ANC utiliza-
tion and adequacy of number of ANC visits. Respondents who reported distances
to health facilities as a problem were half less likely to have accessed ANC services.
In poor resource settings, distances could pose a serious threat to health care acces-
sibility (Fagbamigbe & Idemudia, 2015). Although these women may not have
money to cover transport costs on one hand, they may consider the opportunity
costs of transportation time on the other hand and decide to jettison health
 HEALTH CARE FOR WOMEN INTERNATIONAL 33

services. This could be linked to scarcity of health facilities especially in the rural
areas (Omo-Aghoja et al., 2010). There is need to establish more ANC rendering
facilities in rural areas as recommended earlier (Arthur, 2012). Our models showed
that although spouse permission to visit ANC was significant with ANC utilization,
it was not significant with the adequacy of number of ANC visits. Policies should
be strengthened to focus on educating men on the advantages of utilizing ANC
services and encouraging them to support women in accessing ANC services.
We found ANC utilization to reduce with birth orders and with age of the
respondents. This was in agreement with reports of 2013 NDHS (National Popula-
tion Commission [Nigeria] and ICF International, 2014), an Indian report
(Chandhiok et al., 2006) and a Ghanaian study that all stated that ANC usage fell
as the age of the expectant mother increased and with an increased number of chil-
dren (Arthur, 2012). Although this is at variance with a Colombia report (Ortiz,
2007), negative attitudes of some older women to ANC and the tendency to neglect
ANC due to overconfidence or a previous unpleasant experience could have con-
tributed to this finding. This calls for policies that will ensure adequate ANC serv-
ices and will also educate and promote ANC utilization among all women
irrespective of parity.

Conclusion
Nigeria, like other developing countries, is lagging behind in ANC utilization and
disproportionately bears the burden of maternal death and ill health compared with
the developed countries. Ironically, ANC use is lowest among women who need it
most. These are the poor, uneducated women living in rural areas. Despite the prev-
alent free maternal health care policy in Nigeria, we found poverty and poor educa-
tional attainment to have influenced ANC utilization and adequacy of number of
ANC visits more than any other factor. These have created health inequalities, a
societal problem that must be addressed through effective systems because it under-
mines the economy, heightens social costs, and reduces overall well-being. Although
some state governments in Nigeria had introduced and implemented free ANC pol-
icy, it is alien in some states. There are other direct and indirect opportunity costs,
however, associated with ANC use with which the expectant mothers have to con-
tend. Beyond free maternal and child health care, poverty must be dealt with at indi-
vidual and household levels in Nigeria for the country to compete favorably with
other countries as far as ANC utilization is concerned.

Policy implications
Locally adopted, national and international ANC policies and guidelines must be
put in place to offer free qualitative ANC services to women, irrespective of their
socioeconomic status, tribes, religions, or places of residence. The policies should
focus on eliminating health inequalities by effectively removing all forms of bar-
riers in accessing ANC utilization by the less privileged. This will go a long way in
34 A. F. FAGBAMIGBE AND E. S. IDEMUDIA

reducing health gaps among individuals in Nigeria. Government and her partners
may have to go far beyond providing free maternal health services to adequately
empower the women with quality formal education and functioning health educa-
tion and promotion. One of the strategies of free ANC policy should be imple-
menting free ANC services accompanied with free drugs and consumables to the
doorsteps of the pregnant women. This can be achieved by either building cottage
hospitals in every locality or engaging and empowering community health officers
and extension workers to effectively reach out to the expectant mothers. Beyond
mere contact with ANC providers, an adequate number of ANC visits must be
encouraged in Nigeria and in other countries facing poor ANC utilization. Barriers
to accessing ANC such as finances and long distances should be eradicated through
implementation of free ANC services while spouses are encouraged to support
their wives in accessing ANC services.

Study limitations
This study is limited by its cross-sectional nature. Because the data analysis was
restricted to one point in time, we could not assess the impact of wealth on ANC
utilization over time. Data for the study were self-reported, and this could be
potentially affected by recall bias. The data could also be affected by tendency of
respondents to give socially desirable answers. Finally, our findings are limited to
Nigeria and cannot be generalized to other African countries.

Acknowledgments
We acknowledge the Federal Ministry of Health for allowing the use of this data and the techni-
cal support received from the Consortium for Advanced Research and Training in Africa
(CARTA).

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