CHAPTER TWO

LITERATURE REVIEW

2.1 Overview

Antenatal Care Services (ANC) has proven to be an effective approach towards improving the
health of pregnant women and child and increasing the survival rate of both during pregnancy
and childbirth (Rwabilimbo et al., 2020).

Regrettably, despite the benefits obtained from the use of ANC services in terms of reducing
maternal and neonatal mortality, ANC services is still being underutilized in Nigeria
(Oluwamotemi et al., 2020). Nigeria and India had the highest estimated numbers of maternal
deaths, accounting for approximately one third (35%) of estimated global maternal deaths in
2017 (World Health Organization, 2019).

2.2 Antenatal Care Services in Government Healthcare Facilities

Government or public healthcare facility is the principal source of care for the Nigerian
population. This is supported by Adewoye et al. (2013); Abimbola et al. (2016) and Iyaniwura &
Yussuf (2009) where more than half of the women that attended antenatal care when they had
their last pregnancy did so in a public health facility. Despite the fact that the cost of services
are cheaper in government facilities than private ones, ANC services among other health
services are still being underutilized.

2.3 Factors Affecting the Utilization of Antenatal Care Services

Regular attendance at ANC facilities can prevent some of the complications associated with
pregnancy and childbirth. However, proper antenatal care utilization will be accomplished only
if the factors causing poor utilization of antenatal care services are known (Onasoga et al.,
2012).

The ability to utilize ANC services in developing countries is affected by a number of factors
(Fagbamigbe et al., 2013; Ali et al., 2018). In investigating the factors affecting ANC utilization,
Andersen’s behavioral model of health service utilization (Andersen 1995; Andersen and
Newman 2005) can aid in conceptualizing these factors (figure 1). The model was developed in
1968 by the US medical sociologist and health services researcher Ronald M. Andersen. The
Andersen framework is a health behaviour model that aids in the investigation of key
contributing factors affecting health services utilisation and is one of the most widely
acknowledged models in health care utilization (Babitsch et al., 2012; Srakar et al., 2016; Ali et
al., 2018).

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Figure 2. 1 Andersen’s Behavioral Model of Health Services Use
Source: (Andersen, 1995)

The model has been adopted by a number of researchers to study the factors associated with
the utilization of ANC services (Amin et al., 2010; Ali et al., 2018; Mbugua & MacQuarrie, 2018;
Okonofua et al., 2018; Okedo-Alex et al., 2019; Neupane et al., 2020; Rwabilimbo et al., 2020;
Tolera et al., 2020).

According to the Andersen’s behavioral model, the factors affecting health services utilisation
are categorized into three broad areas namely predisposing factors, enabling factors and need
factors (Andersen, 1995; Andersen & Newman, 2005).

Predisposing factors refer to individual traits that exist prior to the pregnancy and affect the
predisposition towards health care use. Enabling factors refer to the conditions that permit
individuals to obtain health services refer to conditions that make ANC available to pregnant
women. The need factors include perceived illness or the odds of getting into a life-threatening
situation.

With respect to ANC, predisposing factors include demographic characteristics such as age, sex,
marital status. Enabling factors refer to conditions that facilitate the accessibility of ANC. These
include family income, availability of health insurance coverage. The need factors include

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pregnancy-related illnesses such as severe headache, high fever. The modified model for ANC
utilization is shown in figure 2.

Figure 2. 2 The conceptual model for ANC service utilization adapted from Anderson’s
Behavioral Model of Health Services Use

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Some of the important factors affecting utilization of antenatal care services are discussed
below in details.

Education

Abimbola et al. (2016) reported that respondents with higher educational exposure utilized
antenatal care services more than those with lower or no education. This finding is consistent
with the results of several studies in which strong relationship has been demonstrated between
the level of education and utilization of maternal health care services (Mekonnen & Mekonnen,
2003; Babalola & Fatusi, 2009; (Iyaniwura & Yussuf, 2009; Dairo & Owoyokun, 2010; Onasoga et
al., 2012; Ogunba & Abiodun, 2017; Neupane, et al., 2020). This is not surprising as educated
women are often likely to be more aware of health issues and the available health care services
that in turn makes them utilize the services more efficiently than their non-educated
counterparts do (Dairo & Owoyokun, 2010; Onasoga et al., 2012; Abimbola et al., 2016;
Nwankwo & Ezenwaka, 2020).

This is consistent with Eijk et al. (2006) in their study in rural western Kenya where women with
over 8 years of education attended ANC more than those with lesser years of education did.
Saseendran et al. (2007) in a study carried out in India also found women with a secondary
school education or more were more likely to attend ANC than women with primary school
education or less. Jat et al. (2011) and Ali & Chauhan (2020) also reported that mother’s
education is one of the strongest individual level factors influencing the use of ANC services in
India.

However, Dairo & Owoyokun (2010) in their study carried out in Ibadan, Nigeria observed that
level of education had no influence on the utilization of ANC services. They reported it could
possibly be due to the fact the level of awareness on the significance and benefits of antenatal
care cut across the different levels of education in that community.

Marital status

Results from various studies have found mixed evidence of an association between marital
status and utilization of ANC services. For instance, Onasoga, et al., 2012 discovered that there
was a positive correlation between marital status and the utilization of ANC services. In their
study, the married women utilized ANC services more than the single mothers did while the
divorced mothers utilized the services the least. Likewise, Dairo & Owoyokun (2010) observed
married women were more likely to attend ANC clinic compared to women who were single,
separated or divorced than the single mothers. In their study, the single mothers reported that
they were mostly left out of the decision-making on matters that affects their health.

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Source of information / influence

Fagbamigbe et al. (2013) observed that almost half of the respondents obtained information
about ANC services from health workers while others were informed through relatives, news
media and friends. Adewoye et al. (2013) in their study also observed that majority of those
who attended ANC were advised by their mothers while the rest were advised by their
husbands and friends.

Onasoga et al. (2012) also reported that hospital was the first source of information for close to
50% of the respondents. Schools, friends and other means of information were also reported as
major sources of information. Iyaniwura and Yussuf (2009) also reported friends, relations and
health workers as vital sources of information.

Studies carried out in Nepal (Neupane et al., 2020) and India (Ali & Chauhan, 2020) have shown
that women having exposure to radio, TV, and newspaper were likely to attend ANC more
frequently than those without access to these mass media outlets.

Knowledge of Antenatal Care Services

Studies have revealed that sufficient knowledge of the benefits of ANC and of the complications
associated with pregnancy plays an important role in the utilization of ANC services (Ali et al.,
2018). Onasoga, et al., 2012 observed that there was significant association between
knowledge of respondents and their attendance at ANC. They observed that over 80% of the
respondents are/were aware of the services rendered at antenatal clinic.

Adewoye et al., (2013) in their study in North Central Nigeria also observed that close to 90% of
the respondents were conversant with antenatal care. They attributed this to the high literacy
status of the respondents and high level of awareness of antenatal care. They also reported
that over two-thirds of them had good knowledge of the activities carried out under antenatal
care services. This is similar to Abimbola, et al. (2016) who also observed that majority the
respondents were aware of antenatal services though less than half of them had very sound
knowledge of the activities carried out during the ANC services. Studies in Southwest Nigeria
(Iyaniwura & Yussuf, 2009; Fagbamigbe et al., 2013) also reported that almost 90% of
respondents were aware of antenatal facilities in the community.

Having a sound knowledge of ANC services is very important for women. This is evident from
the study of Oluwamotemi et al. (2020) where they discovered that over half of the women did
not know ANC should commence immediately following the confirmation of a pregnancy and
more than 60% of them were ignorant of the fact that ANC helps in timely discovery of
complications in pregnancy. This was ascribed to factors like the level of education of mothers,

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the regularity of ANC visits, the time of ANC commencement and the source of information
about ANC and the knowledge circulated among mothers (Oluwamotemi, et al., 2020).

High socio-economic status

Abimbola et al. (2016) observed that high socio-economic status and utilization of antenatal
and delivery services are positively correlated. This is consistent with other studies in Nigeria
(Babalola & Fatusi, 2009; Iyaniwura & Yussuf, 2009; Nwankwo & Ezenwaka, 2020). It is also in
line with studies in Kenya (Eijk et al., 2006), Tanzania (Mrisho et al., 2009; Rwabilimbo et al.,
2020) and some parts of Asia (Amin et al., 2010; Jat et al., 2011).

Babalola & Fatusi (2009) buttressed this fact by reporting that women with higher socio-
economic status were likely to utilize ANC services almost six times more than those with very
low socio-economic status.

Financial Constraint(s)

Financial Constraint has been reported as a major hindrance towards accessing the ANC in
Nigeria (Fagbamigbe & Idemudia, 2015; Abimbola et al., 2016; Ekpenyong et al., 2019;
Nwankwo & Ezenwaka, 2020). United Nations reported that poverty is a major barrier to ANC
utilization across developing countries (United Nations, 2013). Ekpenyong et al. (2019)
acknowledged financial necessity as a compelling factor for poor decision making concerning
seeking care in health facilities. The study by Ogundairo & Jegede (2016) revealed that majority
of the women took herbs during pregnancy which they linked to lack of financial capability to
seek healthcare services.

Parity

Mekonnen & Mekonnen (2003), in their study in Ethiopia discovered that women with lesser
children tend to use ANC services more than those with higher number of children which
implied that the higher the parity, the less frequent the use of ANC services. This is also similar
to the study conducted in Kenya (Van Eijk et al., 2006), India (Ali & Chauhan, 2020). The anxiety
of first pregnancy can make women more cautious and willing to seek medical care to avoid
complications that may lead to women of higher parity relying on the experience and
knowledge from previous pregnancies and not attending ANC as expected (Ali & Chauhan,
2020).

However, Abimbola et al. (2016) in their study in North-Central Nigeria established that parity
had a positive correlation with utilization of ANC services that implied that women with higher
number of children used ANC services more frequently than those with lower number of
children.

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Surprisingly, some studies have reported that that parity is not a defining factor in the use of
ANC services (Babalola & Fatusi, 2009; Dairo & Owoyokun, 2010; Onasoga, et al., 2012).

Distance

Reports have revealed that the negative correlation between long distances and attendance of
ANC (Onasoga et al., 2012; Ekpenyong et al., 2019; Nwankwo & Ezenwaka, 2020). Trekking long
distances or lack of adequate transport facilities can be tedious for pregnant women.
(Fagbamigbe & Idemudia, 2015 discovered that nearly half of those who did not go for ANC
services complained of the far location of the facilities. They attributed that the problem of cost
of transportation to lower educational level, poorer economic status, Northern zones, ethnicity
and employment status of the respondents. This finding was resonated in the study by
Ekpenyong et al. (2019) on the premise that many of the women did not have readily available
transportation to visit healthcare facilities hence have to depend on their husbands for support.
Griffiths & Stephenson (2001) concluded that women tend to attend ANC services more when
the service is within reasonable distance of the women’s place of residence.

Communication barrier

Though communication barrier is not a common factor reported as affecting ANC services, it is
still an aspect to look into in a multilingual society like Nigeria. Ogundairo & Jegede (2016)
studied communication barrier as a factor affecting utilization of ANC services. They discovered
that women from a culturally and linguistically diverse (CALD) background could discourage
them from utilizing ANC and other health care services due to language barrier.

Age

Iyaniwura & Yussuf (2009) in their study in South Western, Nigeria reported that a higher
proportion of the women who were less than 20 years did not use ANC facilities compared to
women in the older age groups. This is similar to the study of Dairo & Owoyokun (2010) and
Oluwamotemi et al. (2020), both in South Western, Nigeria, where they observed that women
who were 25 years or more were more likely to attend ANC clinic more than women who were
less than 25 years. The authors suggested that this might be due to the older women being
more knowledgeable and more aware of the benefits thereby placing more importance on
modern health care (Dairo & Owoyokun, 2010). It could be reasoned that young women may
lack social support and unwilling to utilize maternity health services (Iyaniwura & Yussuf, 2009).
They may also need financial support and may require husband’s permission before seeking
health care (Ekpenyong, et al., 2019).

In contrast, Studies in India (Jat et al., 2011; Ali & Chauhan, 2020) indicated that pregnant
women who were younger have a tendency to use antenatal care more which implied that with

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the increase in age, the utilization of ANC services goes on decreasing. This is also consistent
with the studies in Tanzania (Rwabilimbo, et al., 2020).

It has also been reported in some studies that age of the women is not a significant barrier to
utilization of antenatal services (Babalola & Fatusi, 2009; Abimbola et al., 2016). Babalola &
Fatusi (2009) explained that the use of ANC services initially increases up to a level and
decreases thereafter.

Employment Status / Occupation

Abimbola et al. (2016) reported that women who were gainfully employed utilized ANC services
more than those who were not employed.

Dairo & Owoyokun (2010) discovered that the type of occupation of husbands of respondents
had a significant relationship with the level of attendance of ANC services. In their study,
respondents whose husbands were professionals tended to utilize ANC services more than
those whose husbands were skilled and unskilled.

Quality of Service

In the study of Abimbola, et al., (2016), women that attended ANC reported to have obtained
evidence-based services like counseling, malaria prevention treatments, health education and
other pregnancy related health services that may have increased their utilization of ANC
services.

Fagbamigbe & Idemudia (2015) in their study discovered that many did not attend ANC clinic
because of lack skilled health workers, poor attitudes of the workers, lack of trust with their
personal information and inadequate good drugs for them. They concluded that poor attitude
and unprofessional conduct of health workers made up over a quarter of the reasons why
pregnant women did not utilize the ANC services. This is also similar to Ogundairo & Jegede
(2016) where their findings reveal that most women preferred private healthcare centres
because of no preferential treatment based on culture or ethnic group usually found in public
healthcare centres.

Ekpenyong et al. (2019) and Oluwamotemi et al. (2020) also reported that stress in the
healthcare centres, long waiting time and poor attitude of health care workers discouraged
pregnant women from utilizing ANC services.

Culture and Influence

The patriarchal structure of the society like Nigeria has an effect on the ability of women to
utilize ANC services as some may require husband’s permission and social support (Ogundairo

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& Jegede, 2016; Nwankwo & Ezenwaka, 2020). Iyaniwura & Yussuf (2009) who observed that
almost over 90% of the respondents still sought their husband’s permission before seeking
health care support this claim.

This is in contrast with the study in Kenya (Van Eijk et al., 2006) where most women made
independent decision to attend ANC. Likewise, Dairo & Owoyokun (2010) reported that
respondents who make decisions alone concerning their health or decide together with their
husbands were more likely to utilize ANC more than those whose decisions are made solely by
their husbands or someone else.

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