Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria

Introduction Utilization of antenatal care, institutional delivery and postnatal care services in Nigeria are poor even by african average. Methods We analysed the 2013 Nigeria DHS to determine factors associated with utilization of these health MCH indicators by employing both bivariate and multivariate logistic regressions. Results Overall, 54% of women had at least four ANC visits, 37% delivered in health facility and 29% of new born had postnatal care within two of births. Factors that consistently predict the utilization of the three MCH services are maternal and husband's level education, place of residence, wealth level and parity. Antenatal care strongly predicts both health facility delivery (OR = 2.16, 95%CI: 1.99-2.34) and postnatal care utilization (OR = 4.67, 95%CI: 3.95-5.54); while health facility delivery equally predicting postnatal care (OR = 2.84, 95%CI: 2.20-2.80). Conclusion Improving utilization of these three MCH indicators will require targeting women in the rural areas and those with low level of education as well as creating demand for health facility delivery. Improving ANC use by making it available and accessible will have a multiplier effect of improving facility delivery which will lead to improved postnatal care utilization.


Introduction
Recent estimates show that the overall ante-natal care (ANC) coverage in Nigeria stood at 61% which is an abysmal three percentage points increase from 58% a decade ago; 36% of deliveries were delivered in a health facility while only 14% of newborns received postnatal care within two months of delivery [1].
The ANC coverage of 61% falls short of the recommended 90% of ANC coverage required to reduce most deaths among mothers and their newborn [2]. Additionally, this national average conceals major variations between rural and urban areas as well as between states and geopolitical zones within the country. For instance, the rural and urban ANC coverages are 47% and 86% respectively; the North West zone has the least of 41% while the South East has the highest coverage of 91%. Institutional delivery show similar regional and rural/urban disparity where it is highest in urban areas (63%) than in rural areas (23%); highest in South West zone (76%) and lowest in North West (12%); the consequence of these differentials of coverage in ANC is that maternal and child health mortality remains high (as well as other indicators of maternal and child health) at national level despite the co-existence of high national coverage in ANC [1]. Furthermore, despite high coverage of ANC, Nigeria still remains a major contributor of under-five mortality, contributing about 13%, 9.4% and 14% of global under-five, neonatal and maternal deaths respectively [3,4]. Expectedly the maternal mortality, neonatal, post-neonatal, infant, child and under-5 mortality rates remain high at 576 maternal deaths per 100000 live births; 37, 31, 69, 64 and 128 per 1000 live births respectively.
These figures show a reduction of between 20% and 31% in the past decade but not enough to achieve MDGs 4 and 5 [1].
In the continuum of maternal health care, antenatal care, institutional/skilled attendance at delivery and postnatal care are important milestones required to achieve optimum maternal and child health. These elements of care are expected to be provided as a continuum of care in order to impact optimum benefit and the provision of these elements of care in a comprehensive and continuum pattern of care during pregnancy, child birth and postpartum period has been argued to reduce maternal and child (neonatal) death [2]. Firstly, antenatal care which is entry point for maternal and child care service utilization has the capability to reduce both maternal and neonatal mortality by detecting at-risk pregnancy and managing the risk associated. It also has additional secondary benefit of providing a platform for interaction between the medical personnel and the pregnant woman during which relevant information and education concerning the health of the mother and her unborn child is passed as well as screening for infections such as syphilis and HIV and other abnormalities and complications. Antenatal care affords the medical personnel the opportunity to detect and treat symptomless ailments such high blood pressure and pregnancy-induced diabetes and facilitates informed decision-making by the pregnant woman such as seeking skilled attendance at delivery and delivery in health care facility. All these interventions received by the pregnant woman during ANC have the potential to improve the survival chance of herself and her newborn [4][5][6][7]. Additionally, an extended benefit of ANC is that women who utilized ANC are more likely to utilize institutional/skilled delivery [8]. The second element of care, institutional delivery/skilled attendance at delivery allows provision of intervention to detect risk around labour and childbirth during which interventions can maximally be provided by skilled medical personnel at health facilities [9]. The third element of care, postnatal care has been argued that promoting the utilization of ANC and institutional delivery/skilled attendance at delivery alone is not enough to improve maternal and child health and that postnatal care has to be provided to sustain the reduction in neonatal mortality [10,11]. Furthermore, more than two-thirds of neonatal deaths occur within the first seven days of life and over half of these taking place in the first 24hours of life; implying that the first 24 hours of life are critical in newborn survival. However, in spite of its potential role in reducing newborn and maternal deaths, postnatal care has been one of the elements of newborn care that is poorly provided and poorly utilized; only around 14% of all newborns had post natal care within the first two days of delivery in Nigeria [1].
However, despite the benefits derived from utilization of focused antenatal care, institutional delivery and postnatal care in terms of reducing maternal and neonatal mortality, Nigeria does not seem to be making progress in terms of these services. While there are several studies documenting factors related to utilization of antenatal care and institutional delivery/skilled attendance at delivery in Nigeria [12][13][14][15][16][17][18][19][20][21][22][23][24][25]

Study variables
The outcome/dependent variables for this investigation are three.

Statistical analyses
First, descriptive statistics related to utilization of ANC, place of delivery and postnatal care were generated by means of frequency  have higher rate of utilization of postnatal care than those in the other two faiths. There is wide margin of utilization between women of parity one (35%) and those with parity five and more (23%).

Results
Likewise, the sex of the household head was women in femaleheaded households have higher utilization rate (37%) than those in male-headed households (28%). Women whom wanted their pregnancy then (27%) utilized postnatal care less than those whom wanted it later (41%) or wanted no more (42%). Facility delivery seems to facilitate utilization of postnatal care; about half (48%) of those who delivered in a health facility accessed postnatal care compared to only 11% among home delivery. Health insurance also plays to facilitate use of postnatal more as obtained with ANC and facility delivery.

Univariate and multivariate analyses
The results of the univariate logistic regressions are shown in Table   3. Again, it shows similar semblance to the results obtained in

Discussion
The purpose of this study was to determine the factors influencing the utilization of antenatal care (ANC), health facility delivery and postnatal care among Nigerian women using the 2013 Nigeria DHS data set. Use of ANC as well as institutional delivery remains some of the important strategies in reducing maternal and child morbidity and mortality [33]. Nigeria continued to be one the largest sources of maternal and child mortality worldwide [3,34] and therefore, investigating the determinants of ANC, institutional use of delivery as well as postnatal care will provide evidence for policy directions and basis for programmatic planning as we approach end of 2015 and begin to plan for the post-2015 development agenda.

Antenatal care
The results from this study showed that at least 51% of women had at least four ANC visits during their last pregnancies which fall short of the required level of 90% [2].  have been studied by several researchers in the past; of note is that by Bloom [5]. Story and Burgard reported that joint decision between the wife and husband predicts positive use antenatal care and skilled delivery compared to husband-only [49]. Our adjusted model for use of ANC revealed an increased chance of ANC by the woman-husband pair but not statistically significant. As for facility delivery, woman-alone influences health facility delivery more than woman-husband pair; that is if both the wife and husband are jointly making decision about place of delivery then the woman has a chance of 30% to deliver in a health facility compared to when the woman alone is making the decision which is 36%.

Institutional delivery
It is estimated that every year about 60 million births occur outside the health facility at home, of which 52million of these births are not attended by skilled medical personnel [50]. Access to skilled care at birth is one the strategies that can reduce both maternal and child mortality; however this access is lowest in sub-Saharan Africa and Educated husband are more likely to provide support to their wives to utilized formal health services such as facility delivery [54]. The role of partner's level education on health facility delivery has not been on the spotlight in Nigeria until recently; perhaps the work of Aremu [12] might be among the first few to highlight this important factor. We found that husband's level of education has a positive influence on health facility delivery up to a point where women whose husbands had tertiary level education have about 61% increased probability of facility delivery. Previous researches showed a rural disadvantage in utilization of health services, here also rural residence confers some level of disadvantage on the use of health facility for delivery; those in rural areas were about 35% less likely to use health facility for delivery. The rural disadvantage could be due to access, cost of services, distance and travelling time as well as opportunity cost of leaving place of work to attend health facility and lack of skilled personnel at these health facilities that can lead to poor outcome and poor satisfaction. This finding is not surprising considering the acknowledged spatial distribution of health facilities in low and medium income countries like Nigeria as well as low socioeconomic level of rural people that serves as financial barrier to access health service [55,56]. Regarding religion, though the odds ratio indicates increased utilization of health facility for delivery, this is not significant. Presence of male medical personnel may deter some Muslim women from accessing health facility for delivery and may use traditional birth attendants for this purpose [56].
Household wealth, parity, enrolment into insurance scheme appeared to be common factors responsible for both use of ANC and facility delivery; and that use of ANC positively predicts use facility delivery. These findings are common in literature where an inverse relationship between parity and use of facility delivery [57,58]; positive relationship between household wealth index with facility delivery [12,59,60] and increased use of facility delivery as a result of health insurance enrolment [12,[61][62][63]. Our study therefore, further confirms the pattern and nature of the influence of these factors on the utilization of facility delivery in Nigeria.
Previous findings relating to utilization of facility delivery to ANC use is that of positive influence of ANC on use of facility delivery. This study was able to identify this positive role played by ANC utilization on facility delivery; a woman who had at least four ANC visits was more than two times more likely to have delivered in health facility than those with zero ANC attendance. Previous studies documented that ANC-related factors that increased chance of facility delivery include the timing first ANC visit, number of ANC visits, attended by a doctor, quality of ANC and being advised to deliver in health facility [21,31,53,54,58]. instance, woman with tertiary education is more likely exposed to benefits of postnatal care, more likely to have had ANC and delivered in health facility and therefore these might propel her further to access postnatal care. Living in urban towns/cities made her more exposed to facilities providing postnatal care and that she or her husband might be gainfully employed that makes health services affordable in their places of residences. In this type of family, misconceptions about postnatal care is unlikely to be tenable, and other barriers to utilization of health care such as distance to facility, lack of confidence and the need to be attended by female health worker are unlikely to play any major role as has been elucidated by some investigators [64][65][66][67][68].
A finding of note is the relationship between postnatal care and parity; the higher the parity the less likely to receive postnatal care.
It is possibly related to maternal experience of child birth to extend that those high parity women do not consider postnatal care worthwhile from experience they gather from previous child birth.
This might also explain the reason why higher parity women use facility for delivery as well as ANC less than lower parity as seen in 9 this study. Our study further confirms the influence of ANC and facility delivery on access of postnatal care. ANC provides an opportunity for sending message to the attendees on the benefits of facility delivery and postnatal care. Further, delivery in health facility affords the chance to access postnatal care, even though this is not spontaneous. This relationship has been documented by Titaley [68].

Strengths and limitations
An important strength of this study is the utilization of a nationallyrepresentative sample of women as respondents. With this approach, national averages are generated for the whole country.
However, as can be seen, there are a lot of regional variations the estimates generated; though this could be provide region-based policy direction and programming.

Competing interests
Authors declare no competing interests.

Authors' contributions
TD conceptualized the study, carried out data analysis and wrote the initial draft. MO read the initial draft and made comments.

Acknowledgments
The acknowledged the useful comments of Dr. Latifat Ibisomi of Witwatersrand School of Public Health, Johannesburg. Also we are grateful to MEASURE DHS for permission to use the data set in this study.