Project – Impact of Maternal Health Awareness on the Utilisation of Antenatal Care Services Among Pregnant Women in Selected Primary Health Centres in Ofu LGA

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Maternal health remains a major public health concern because the health and survival of women during pregnancy and childbirth have significant implications for families, communities and national development. Pregnancy is a physiological process, but it can also expose women to complications that may threaten the life of the mother or unborn child. Hypertensive disorders, haemorrhage, anaemia, infections, malaria, gestational diabetes and other pregnancy-related complications can contribute to maternal and perinatal morbidity and mortality when they are not detected and appropriately managed. Consequently, maternal health programmes increasingly emphasise preventive care, early identification of risks, skilled healthcare and appropriate utilisation of antenatal care (ANC) services.

Antenatal care is an essential component of the continuum of maternal and reproductive healthcare. It provides an important platform through which pregnant women can receive health education, screening, preventive interventions, counselling, treatment and referral when complications are identified. The World Health Organization (WHO, 2016) describes ANC as an opportunity for health promotion, screening, diagnosis and disease prevention during pregnancy. The WHO therefore recommends that ANC should go beyond simply counting visits and should provide meaningful contact between pregnant women and skilled healthcare providers.

The importance of ANC is particularly evident in settings where maternal and newborn health challenges remain substantial. Regular contact with skilled healthcare personnel enables health workers to monitor maternal and fetal well-being, identify danger signs, provide appropriate preventive interventions and educate women about healthy pregnancy practices. The WHO’s 2016 ANC model recommends a minimum of eight contacts during pregnancy, beginning in the first trimester, because increased opportunities for assessment and communication can facilitate the timely detection and management of complications.

The first ANC contact is particularly important because early registration enables healthcare providers to establish a woman’s health status, identify pre-existing conditions, estimate gestational age and initiate appropriate preventive interventions. Subsequent contacts provide opportunities for monitoring pregnancy progression and addressing emerging problems. The WHO recommends contacts at approximately 12, 20, 26, 30, 34, 36, 38 and 40 weeks of pregnancy. The model also emphasises counselling on nutrition, physical activity, substance use, malaria and HIV prevention, iron and folic acid supplementation, tetanus vaccination and other appropriate interventions.

The utilisation of ANC services is therefore not merely a question of whether a woman attends a health facility at least once. Quality utilisation involves early initiation, adequate frequency of contacts and receipt of essential ANC interventions. WHO (2016) specifically notes that the purpose of the ANC model is to provide women with respectful, individualised and person-centred care, supported by effective clinical practices, relevant information and psychosocial support. Thus, the effectiveness of ANC depends partly on whether pregnant women understand the purpose of the service and recognise the importance of attending regularly.

Maternal health awareness is an important factor that may influence ANC utilisation. Maternal health awareness refers broadly to a pregnant woman’s knowledge and understanding of pregnancy-related health issues, danger signs, preventive measures, available maternal health services and the importance of seeking professional care. A woman who understands the purpose of ANC may be more likely to register early, attend scheduled contacts, comply with recommended tests and treatments, and seek assistance when danger signs occur. Conversely, inadequate awareness may contribute to late registration, irregular attendance or reliance on informal sources of care.

Health awareness can influence maternal behaviour through several pathways. First, awareness can increase a woman’s perceived susceptibility to pregnancy-related complications. Second, it can improve her understanding of the benefits of professional maternal healthcare. Third, it can help her recognise pregnancy danger signs and appreciate the importance of seeking timely care. Fourth, it can increase her knowledge of preventive interventions such as tetanus vaccination, iron and folic acid supplementation, malaria prevention, nutritional counselling and screening. In this regard, maternal health awareness is not simply the possession of information; it involves understanding information sufficiently to make appropriate health decisions.

Evidence from Nigeria indicates that ANC utilisation remains influenced by maternal education, exposure to information, household resources, residence and other socioeconomic factors. Fagbamigbe et al. (2018), using nationally representative Nigerian data, found that underutilisation and inadequate receipt of ANC components were associated with factors including rural residence, lack of maternal education, unemployment, long distance to health facilities, limited media exposure, low household wealth and home birth. The authors recommended appropriately guided health education messages, among other interventions, to improve ANC uptake.

The relationship between education and ANC utilisation has also been demonstrated in more recent Nigerian analyses. Using the 2018 Nigeria Demographic and Health Survey (NDHS), Yaya et al. (2020) found that only about 17.4% of women in their study had eight or more ANC contacts. Women with at least secondary education were substantially more likely to achieve eight or more contacts than women without formal education, while women exposed to media were also more likely to achieve the recommended number of contacts. The study further found that delayed initiation of ANC was associated with lower odds of achieving eight or more contacts.

Similarly, spatial and multilevel analysis of the 2018 NDHS demonstrated that maternal education, partner’s education, employment status, parity, media exposure, wealth, place of residence and community literacy were associated with incomplete ANC attendance in Nigeria (Okedo-Alex et al., 2021). The findings indicate that ANC utilisation is influenced by a combination of individual, household and community factors rather than by the availability of health facilities alone.

Adewuyi et al. (2018) also found considerable differences in ANC utilisation between rural and urban Nigerian women. Their analysis of the 2013 NDHS showed that underutilisation was considerably higher among rural women than urban women. Factors associated with underutilisation included socioeconomic conditions, media exposure, financial constraints and the ability to obtain support for visiting health facilities. These findings suggest that improving ANC utilisation requires attention not only to service availability but also to women’s knowledge, socioeconomic circumstances and ability to make decisions concerning their healthcare.

More recent analysis of the 2018 NDHS further demonstrates the continuing importance of disparities in maternal healthcare utilisation. Adewuyi et al. (2024) reported that utilisation of eight or more ANC contacts was approximately 20.3% nationally, with considerably higher utilisation in urban areas than rural areas. Maternal and partner education, health insurance and maternal autonomy were among the factors associated with increased ANC utilisation. The findings also indicated differences in the receipt of ANC components such as iron supplementation, tetanus vaccination and drugs for intestinal parasites.

The Nigerian situation is particularly important because maternal healthcare utilisation can be affected by both demand-side and supply-side factors. On the demand side, women may lack adequate knowledge, financial resources, autonomy or family support. On the supply side, factors such as distance, availability of healthcare workers, quality of care, waiting time, cost of services, availability of medicines and the attitude of health workers may affect women’s willingness to use ANC services. Thus, maternal health awareness represents one potentially modifiable factor within a broader set of determinants.

Health education is an important mechanism for improving maternal health awareness. During ANC sessions and community health programmes, healthcare workers can educate pregnant women about the importance of early registration, recommended ANC contacts, nutrition, personal hygiene, malaria prevention, immunisation, medication adherence, birth preparedness, danger signs and emergency referral. WHO (2016) specifically incorporates communication, counselling and health education into the ANC model, recognising that effective communication between pregnant women and healthcare providers is essential to a positive pregnancy experience.

Community-level awareness is also important. Pregnant women do not make healthcare decisions in isolation. Their partners, parents, relatives, friends, religious leaders and community members may influence when and where they seek care. In communities where pregnancy is strongly influenced by traditional beliefs or where informal providers are easily accessible, health awareness programmes can provide evidence-based information that helps women distinguish between normal pregnancy experiences and symptoms requiring professional attention.

This issue has particular relevance in Kogi State. Research among Igala women in Kogi State found that cultural norms, proximity of traditional birth attendants, operating hours of primary healthcare facilities and limited awareness of services available in PHCs can affect the utilisation of maternal health services. The study specifically identified lack of awareness of the services available in primary healthcare facilities as a factor limiting use. Although the study was qualitative and covered broader maternal health services, its findings are relevant to understanding the context in which pregnant women make decisions about facility-based care in Kogi State.

Ofu Local Government Area is located in Kogi State and contains communities where primary healthcare centres constitute important points of access to maternal and child health services. For many pregnant women, PHCs provide an accessible platform for ANC, health education, routine monitoring, immunisation-related services, counselling and referral. However, physical availability of a PHC does not necessarily guarantee that pregnant women will utilise its services adequately. Women must be aware of the services provided, understand their benefits and perceive ANC as necessary for protecting both their own health and that of their unborn babies.

The role of maternal health awareness is especially important in rural and semi-rural communities where formal health information may compete with traditional knowledge and beliefs. Pregnant women may receive advice from older relatives, traditional birth attendants, peers, religious groups, social media and healthcare workers. While some of these sources can provide useful support, others may provide incomplete or inaccurate information. Appropriate maternal health education can therefore help women make informed decisions based on scientifically supported information.

Another important issue is the timing of ANC initiation. Early initiation gives healthcare providers a longer period within which to monitor pregnancy and provide preventive interventions. WHO recommends that the first ANC contact occur during the first trimester, preferably by 12 weeks of gestation. However, Nigerian evidence shows that delayed initiation remains common and is associated with lower likelihood of achieving adequate ANC contacts. Yaya et al. (2020) found that each additional month of delay in ANC initiation was associated with a substantial reduction in the likelihood of achieving eight or more contacts.

Maternal awareness may influence this timing because a woman who understands the importance of early ANC is more likely to recognise pregnancy early and initiate care promptly. Awareness can also influence continuity. A woman may attend the first ANC appointment but fail to return for subsequent contacts if she does not understand the importance of continued monitoring or if she believes that ANC is necessary only when complications occur. Therefore, assessing awareness in relation to actual utilisation is important.

The issue is not limited to the number of visits. ANC contacts provide opportunities for preventive and diagnostic interventions that can directly affect maternal and fetal health. These include blood-pressure monitoring, screening, nutritional counselling, supplementation, immunisation, malaria prevention, HIV-related services, fetal assessment and preparation for delivery and possible complications. WHO (2016) emphasises that increasing the frequency and quality of ANC contacts provides more opportunities to detect potential problems and to communicate with and support pregnant women.

The quality of communication during ANC can also influence future utilisation. When pregnant women receive respectful treatment and understandable explanations, they may develop greater confidence in health facilities. Conversely, poor communication, disrespectful treatment or inadequate explanations may discourage continued attendance. The WHO ANC model therefore places emphasis on respectful, individualised and person-centred care as a foundation for a positive pregnancy experience.

There is consequently a strong public health rationale for examining maternal health awareness and ANC utilisation among pregnant women attending selected PHCs in Ofu LGA. While national studies provide evidence about the determinants of ANC utilisation, national-level findings cannot fully explain the experiences of women in a specific local government area. Community-specific studies are necessary because cultural practices, socioeconomic conditions, distance, family influence, knowledge and patterns of healthcare utilisation vary between locations.

The present study therefore focuses on the impact of maternal health awareness on the utilisation of antenatal care services among pregnant women in selected primary health centres in Ofu LGA. The study is premised on the expectation that women with higher levels of awareness of maternal health and ANC may be more likely to initiate ANC early, attend recommended contacts and make greater use of available ANC services. Establishing the nature and strength of this relationship will provide useful evidence for improving maternal health education and ANC utilisation in the study area.

1.2 Statement of the Problem

Maternal morbidity and mortality remain important public health challenges in Nigeria despite the existence of maternal and child health programmes and the widespread establishment of primary healthcare facilities. Pregnancy-related complications can often be prevented, detected early or appropriately managed when women receive timely and quality antenatal care. However, the benefits of ANC depend substantially on whether pregnant women initiate care early, attend regularly and receive the essential components of the service.

One major problem is the persistent gap between the availability of ANC services and their adequate utilisation. Although many Nigerian women report at least one ANC contact, a much smaller proportion achieve the recommended number of contacts. Yaya et al. (2020), for example, found that only about 17.4% of women in their nationally representative analysis had eight or more ANC contacts. More recent analysis of the 2018 NDHS estimated eight-or-more-contact utilisation at approximately 20.3%, again demonstrating that adequate ANC utilisation remains limited.

The problem is not only inadequate frequency of attendance but also late initiation of ANC and incomplete receipt of recommended services. Fagbamigbe et al. (2018) reported that nearly half of the women studied had underutilised ANC, while inadequate receipt of ANC components was even more widespread. Factors associated with underutilisation included low maternal education, unemployment, rural residence, distance to facilities, limited media exposure and low household wealth. These findings suggest that inadequate knowledge and limited exposure to appropriate health information may coexist with socioeconomic and structural barriers.

Maternal health awareness is therefore a potentially important component of the problem. A pregnant woman who does not understand the purpose of ANC may not consider early registration necessary. She may also fail to recognise the importance of returning for subsequent appointments after an uncomplicated first visit. In some circumstances, pregnancy may be regarded as a normal condition that requires healthcare only when complications become obvious. Such perceptions can delay professional care and reduce the opportunities available for early detection and prevention.

Another concern is the possible influence of traditional beliefs and informal sources of maternal health information. Pregnant women may receive advice from relatives, traditional birth attendants, friends or community members whose knowledge may not always correspond with recommended maternal health practices. Evidence from Kogi State indicates that cultural norms, proximity to traditional birth attendants and lack of awareness of services available in PHCs can influence maternal healthcare utilisation. In communities where informal providers are more familiar or accessible than formal health facilities, inadequate awareness of the benefits of facility-based ANC may further reduce utilisation.

There is also a problem of inadequate knowledge about the specific services provided during ANC. Some pregnant women may perceive ANC primarily as a place for weighing, routine medication or obtaining an appointment for delivery, without understanding its broader preventive and diagnostic functions. WHO (2016) emphasises that ANC includes health promotion, screening, diagnosis, disease prevention, counselling, nutritional interventions, maternal and fetal assessment and preparation for childbirth. If pregnant women are unaware of these benefits, they may underestimate the importance of regular attendance.

The problem may also involve delayed initiation. The WHO recommends the first ANC contact within the first trimester, but evidence from Nigeria indicates that delayed initiation reduces the likelihood of achieving adequate ANC contacts. A woman who registers late has fewer opportunities to receive preventive interventions and to have pregnancy-related complications detected early. Late booking may consequently contribute to missed opportunities for health education, screening and risk assessment.

In Ofu LGA, the existence of primary healthcare centres provides an important opportunity for improving maternal health. However, the mere availability of PHCs does not necessarily translate into optimal utilisation. Women may face barriers related to awareness, distance, cost, family influence, cultural beliefs, perceived quality of care, health-worker attitudes and competing responsibilities. Among these factors, maternal health awareness is particularly important because it is potentially modifiable through effective health education and community mobilisation.

The lack of locally specific evidence creates an additional problem. National and state-level studies have identified numerous determinants of ANC utilisation, but the relative importance of maternal health awareness among pregnant women using selected PHCs in Ofu LGA is not sufficiently established. Without empirical evidence from the local setting, healthcare planners and community health workers may find it difficult to determine whether inadequate awareness is a major contributor to poor utilisation and which areas of maternal health education require greater attention.

The problem addressed by this study is therefore the possibility that inadequate maternal health awareness may be contributing to delayed, irregular or inadequate utilisation of ANC services among pregnant women in selected PHCs in Ofu LGA. Although ANC services are intended to provide women with essential preventive and promotive care, the extent to which pregnant women’s awareness influences their utilisation of these services requires empirical investigation.

It is against this background that the study seeks to assess the impact of maternal health awareness on the utilisation of ANC services among pregnant women in selected primary health centres in Ofu LGA. The findings are expected to provide evidence that can guide maternal health education, community mobilisation and strategies aimed at improving early and continuous utilisation of ANC services in the study area.

1.3 Aim of the Study

The main aim of this study is to assess the impact of maternal health awareness on the utilisation of antenatal care services among pregnant women in selected primary health centres in Ofu Local Government Area of Kogi State.

1.4 Objectives of the Study

The specific objectives are to:

1. assess the level of maternal health awareness among pregnant women attending selected primary health centres in Ofu LGA;
2. determine the level of utilisation of antenatal care services among pregnant women in the selected primary health centres;
3. identify the major sources of maternal health information among pregnant women in the selected primary health centres;
4. examine the relationship between maternal health awareness and antenatal care utilisation among pregnant women; and
5. determine the extent to which maternal health awareness influences the utilisation of antenatal care services among pregnant women in the selected primary health centres.

1.5 Research Questions

The study will answer the following research questions:

1. What is the level of maternal health awareness among pregnant women attending selected primary health centres in Ofu LGA?
2. What is the level of utilisation of antenatal care services among pregnant women in the selected primary health centres?
3. What are the major sources of maternal health information among pregnant women in the selected primary health centres?
4. What relationship exists between maternal health awareness and antenatal care utilisation among pregnant women?
5. To what extent does maternal health awareness influence the utilisation of antenatal care services among pregnant women in the selected primary health centres?

1.6 Research Hypothesis

The following null hypothesis will be tested at the 0.05 level of significance:

H₀: There is no significant relationship between maternal health awareness and the utilisation of antenatal care services among pregnant women in selected primary health centres in Ofu LGA, Kogi State.

1.7 Significance of the Study

The study will be significant to pregnant women because it will highlight the importance of adequate knowledge about pregnancy, ANC and maternal health practices. Improved awareness may encourage women to initiate ANC early, attend appointments regularly and make better use of preventive and diagnostic services.

The study will be useful to nurses, midwives, community health officers and other healthcare professionals working in primary healthcare centres. Findings will help healthcare workers understand areas of maternal health knowledge that require greater emphasis during ANC education and community outreach programmes.

The study will also be relevant to the management of primary healthcare centres in Ofu LGA. Evidence on the relationship between maternal awareness and ANC utilisation may assist PHC managers in strengthening health talks, counselling, community mobilisation and follow-up systems for pregnant women.

The findings may be useful to the Kogi State Ministry of Health and Ofu Local Government health authorities in planning maternal and child health interventions. If inadequate awareness is found to be an important determinant of ANC utilisation, greater attention can be given to community-based health education and targeted maternal health campaigns.

Community leaders, women’s groups, religious organisations and other community-based organisations may also benefit from the study. These groups can serve as important channels for disseminating accurate maternal health information and encouraging pregnant women to use available health services.

The study will further contribute to academic knowledge on maternal health awareness and healthcare utilisation in Nigeria. Existing studies have established that maternal education, socioeconomic status, media exposure, residence, autonomy and other factors influence ANC utilisation, but locally specific evidence remains important. The findings of this study may therefore provide a basis for future research in Ofu LGA and comparable communities.

1.8 Scope of the Study

The study focuses on the impact of maternal health awareness on the utilisation of antenatal care services among pregnant women in selected primary health centres in Ofu LGA, Kogi State.

The independent variable is maternal health awareness, while the dependent variable is utilisation of antenatal care services. Maternal health awareness will cover knowledge of the importance of ANC, recommended timing of first ANC contact, recommended frequency of contacts, pregnancy danger signs, nutrition, immunisation, malaria prevention, medication and supplementation, birth preparedness and other relevant maternal health issues.

Utilisation of ANC services will be assessed in terms of early initiation of ANC, frequency of attendance, continuity of attendance and utilisation of relevant ANC services and interventions.

Geographically, the study will be restricted to selected primary health centres in Ofu Local Government Area. The respondents will comprise pregnant women receiving or expected to receive ANC services in the selected facilities. The study does not seek to assess all maternal health services or all determinants of maternal mortality in Kogi State.

1.9 Operational Definition of Terms

Antenatal Care (ANC): Healthcare and support provided to a pregnant woman by skilled healthcare personnel during pregnancy for health promotion, screening, disease prevention, monitoring and management of pregnancy-related conditions.

Antenatal Care Utilisation: The extent to which pregnant women initiate, attend and continue using ANC services, including the recommended contacts and relevant maternal and fetal health interventions.

Maternal Health: The health and well-being of women during pregnancy, childbirth and the postpartum period.

Maternal Health Awareness: The level of knowledge and understanding a pregnant woman possesses concerning pregnancy, maternal health risks, danger signs, preventive measures, ANC services and appropriate healthcare-seeking practices.

Pregnant Woman: A female who is currently carrying a pregnancy and is receiving or eligible to receive maternal healthcare services.

Primary Health Centre (PHC): A community-based health facility providing basic and essential healthcare services, including maternal and child health services and ANC.

Health Education: A planned process through which individuals or groups receive information and develop knowledge, attitudes and skills intended to promote health and prevent disease.

Health Information: Facts, advice, guidance and messages concerning pregnancy, maternal health, disease prevention and available healthcare services.

Early ANC Initiation: Registration and commencement of ANC during the first trimester of pregnancy, preferably within the first 12 weeks, in accordance with the WHO ANC model.

Adequate ANC: For the purpose of this study, ANC utilisation that reflects timely initiation, appropriate continuity and sufficient contacts and receipt of relevant ANC interventions. The study recognises the WHO recommendation of a minimum of eight contacts during pregnancy.

Project – Impact of Maternal Health Awareness on the Utilisation of Antenatal Care Services Among Pregnant Women in Selected Primary Health Centres in Ofu LGA