Poor prenatal service utilization and pregnancy outcome in a tertiary health facility in Southwest Nigeria

Introduction Poor prenatal service utilization is common in developing countries. However, the predictors and pregnancy outcomes of poor utilizers have not been fully examined in our setting. Methods Poor and good prenatal service utilizers were compared with respect to demographic characteristics and pregnancy outcomes in Ado-Ekiti, Nigeria. Results Poor utilizers were significantly more likely to be single mothers, with unemployed husbands/partners, but less likely to have labour induction compared with good utilizers. Also, the women with fewer than four antenatal visits had significantly more babies with low birth weight (18% versus 9.8%, p = 0.003), and 5-minute Apgar scores less than 7 (17.9% versus 10.1%, p = 0.023). Multivariate regression analysis revealed that having an unemployed husband/partner (adjusted odds ratio (AOR): 2.33; 95% Confidence Interval (C.I.): 1.24 - 4.38; p = 0.009), with low birth weight babies (AOR: 1.66; 95% C.I.: 1.01 - 2.73; p = 0.045), and delivering without induction of labour (AOR: 4.27; 95% C.I.: 2.38 - 7.64; p < 0.001) were independently associated with poor prenatal service utilization. Conclusion Efforts devoted to identifying women who are likely to be non- and poor-utilizers of prenatal care are recommended. Scaling up awareness campaigns on maximizing the benefits of prenatal care, increasing the content quality of antenatal visits to give women a positive pregnancy experience and implementing a National Health Insurance package that strategically targets the most socially underprivileged classes are advocated to promote safe motherhood and the objectives of antenatal care.


Introduction
Prenatal care provided by skilled personnel has been found to ensure the health of pregnant mothers and improve pregnancy outcomes by identifying and promptly managing pregnancy-related complications [1][2][3]. The benefits of prenatal service utilization include provision of evidence-based clinical interventions, including prevention of mother-to-child transmission of HIV, maternal health education and counselling on birth-preparedness and complicationreadiness. Specialized care can be quickly arranged when the need arises. Besides, women who attend prenatal care are more likely to have facility-based deliveries, and return for postnatal care [4,5]. On the contrary, lack of antenatal care has been clearly linked with increased perinatal morbidity and mortality. While poor utilization of prenatal services is no longer an issue in most developed countries, low-and middle-income nations still grapple with the adverse pregnancy outcomes related to poor antenatal care [6][7][8][9]. Following large, randomized, multi-centre trials that identified evidence-based interventions, clinic-visit patterns that were beneficial and costeffective to pregnant mothers, the World Health Organization (WHO) recommended four focused antenatal visits for all women [10]. This antenatal care [11]. According to the Nigeria Demographic and Health Survey, among women who had a live birth in the five years preceding the survey, 61% received antenatal care from a skilled provider, while 51% of the pregnant women reportedly made at least four antenatal visits during the pregnancy [12]. This poor utilization of prenatal service occurs commonly in developing countries [13]

Data analysis
The retrieved data were coded into, and analyzed using the Statistical Software for the Social Sciences (SPSS) package version 20.
Frequency distribution and percentages were generated from the data. Pearson´s Chi-square test was used to explore the univariate association of the maternal and pregnancy characteristics with prenatal service utilization. Bivariate regression analysis was employed to test the strength of the association between maternal socio-demographic characteristics and pregnancy outcomes with prenatal service utilization, and the results were expressed as crude odds ratio with the corresponding 95% confidence interval. The variables that showed significant association with prenatal service utilization were included in multivariate logistic regression model to identify the independent predictors of poor prenatal service utilization.
The results of the multivariate regression analyses were expressed as adjusted odds ratio at 95% confidence interval (C. I.), with level of significance set at p < 0.05.

Results
Of the 2,139 parturients included in the study, the greater proportion, were independently associated with poor prenatal service utilization (Table 4).

Discussion
Our study did not just seek to compare women who had antenatal care at EKSUTH with those who did not, because that would underestimate the beneficial value of prenatal care. Instead, we sought to explore the potential advantages of adequate antenatal visits/service utilization over poor utilization with respect to pregnancy outcomes.

Statement of principal findings
Interestingly, we found that women who did not utilize prenatal services by a skilled provider were comparable in maternal characteristics and pregnancy outcomes with those who were poor utilizers. Women´s decision to fully maximize the potential benefits of prenatal services in low-income settings is modified by certain factors, including ease of accessing the facility, their perception of the quality of service provided, socio-economic status, level of education, previous pregnancy outcomes and cultural beliefs [7,15,16].
Eliminating these barriers would increase maternal prenatal service utilization. Single/unmarried mothers were more likely to utilize prenatal services poorly. This finding, which has been documented by other authors [17], can be due to lack of social support, teenage pregnancies, unwanted pregnancies and fear of stigmatization. We found that women with unemployed spouses were less likely to fully utilize antenatal care packages. In our largely paternalistic setting, the socio-economic status of women with unemployed husbands may likely be low, which may negatively impact on their attendance at antenatal clinics where they need to pay out-of-pocket [18][19][20]. Our study also revealed that, more women with poor antenatal attendance had babies with 5-minute Apgar scores below 7. The association between lack of antenatal care and perinatal morbidity and mortality has been documented by studies from various countries [6]. This could be the result of an interplay of poor antenatal attendance with social factors like poor health-seeking behaviours of the mothers.
Besides, this category of women might belong to a socially underprivileged group (such as low family income) with increased risk of adverse perinatal outcome [6]. However, having unemployed partners was the only one of these three variables that was associated

Strengths and weaknesses of the study
The results of this facility-based study may not be an exact reflection of the situation in the community. However, since the study setting receives referrals from the primary and secondary health facilities that are closer to the community, the findings may be extrapolated to represent the local population. Also, although the data did not include evaluation of the content of the antenatal visits, this survey has provided salient data that can serve as a template for further studies on the subject.

Meaning of the study
Mothers who had no or less-than-adequate antenatal care have unfavourable perinatal outcomes. Identifying predictors of poor utilization could guide public health interventions aimed at increasing uptake of antenatal care.

Unanswered questions and future research
It is not completely certain if provision of universal access to antenatal care will lead to total acceptance and uptake of prenatal service in our setting. The influence of socio-cultural modifiers of health-seeking behaviour as it relates to prenatal service uptake needs to be explored.

Conclusion
The socio-demographic characteristics and pregnancy outcomes of mothers who had no skilled prenatal care provider did not differ significantly from those of mothers who utilized prenatal services poorly. Furthermore, women who had less than four prenatal visits were more likely to be single, with unemployed partners, and have babies with low birth weight and poor 5-minute Apgar scores. Efforts devoted to identifying women who are likely to be non-and poorutilizers of prenatal care are recommended. Eliminating barriers to accessing prenatal services, and implementing a National Health Insurance package that also targets the most socially underprivileged classes are advocated.

Competing interests
The authors declare no competing interests.  Table 1: maternal socio-demographic characteristics, n = 2,139     89.5 Categorization of the patients into 'good' and 'poor' service utilizers was done only for clients who received prenatal care in the study location.