Seeking evidence to support efforts to increase use of antenatal care: a cross-sectional study in two states of Nigeria

Different operators entered all the data twice with validation using Epi Info [31] to minimise keystroke errors. Analysis relied on CIETmap open source software [32]. We weighted all estimates proportional to the population in each state, including rural and urban characteristics, and adjusted for over-sampling in the focus Local Government Authorities. We did not undertake a combined analysis of the two states, since they were not intended to be representative of a larger entity (such as the nation). Rather we analysed the data for the two states separately, since an explicit aim was to share state-specific findings to support planning at state level and below.

The main outcome was four or more ANC visits to a government health facility in the last pregnancy. Factors examined for their association with the outcome included location of residence (urban or rural), whether the household or individual woman had enough food during the week prior to the survey (as an indicator of absolute poverty), household owning motorised transport, education of the household head and the woman, the woman's exposure to domestic and intimate partner violence, access to health information, number of previous pregnancies, woman receiving help for her routine heavy work at home during pregnancy, and access to health facilities whether within or outside the community (see Table 1). We defined "more education" as junior secondary or above in Cross River and any formal education in Bauchi. In order to produce state specific information about factors associated with use of ANC, we examined the associations in bivariate and then multivariate analysis in each state separately. For the multivariate analysis we used the Mantel Haenszel procedure [33] adjusted for clustering [34] and stepped-down from an initial saturated model including all the variables found significant in the bivariate analysis until we reached a final model of factors all significantly associated with the outcome. We describe associations using the Odds ratio (OR) with the cluster adjusted 95% confidence interval (caCI).

Three of the authors (KO, NJA and MCB) undertook a thematic analysis of the translated focus group reports, to identify emerging themes about reasons for non-attendance for ANC. They continued reading through reports until no new themes emerged, and extracted relevant quotes to illustrate the different themes. We used the qualitative findings from the focus groups to give context to and help to explain the quantitative findings from the household survey in the two states.

During the period from April 2010 till March 2011 we shared the study findings with stakeholders at State, Local Government Authority and community levels. We designed a score card showing values of key indicators for each Local Government Authority with the state average value for comparison. A video docudrama portrayed key messages based on the findings. We conducted workshops, small group and individual meetings with ministries, departments and non-government organisations at state and Local Government Authority level to share the findings and plan actions to increase the use and quality of ANC services. The meetings were timed to allow proposed actions to be included in the budget allocations for 2010-2012.

Field teams conducted structured discussions around the docudrama with community leaders and groups of men and women in order to generate local solutions. The state Ministry of Health in Cross River and the state Primary Health Care Development Agency in Bauchi, with support from the state Ministry of Health, used the evidence to implement a model intervention of pregnancy surveillance in three randomly selected focus Local Government Authorities [35] in each state to improve women's access to ANC. Under this intervention trained female and male health workers and community activists periodically visit all the households in a defined catchment area assigned to them. They use structured evidence based guides to interact with pregnant women, their spouses, and family members to generate an enabling environment for improving care for pregnant women and their access to ANC. They aim to visit each pregnant woman at least four times during the pregnancy.

The Ministry of Health in each state gave formal ethical approval for the study. The trained field teams sought consent for the survey from leaders in each sample community. In each household the interviewers sought verbal consent from the household head, and from each individual respondent. Interviewers did not record any names or personal identity information and were trained not to proceed with any interview unless they could do so without being overheard.

Many of the women participating in focus groups cited problems with services delivery as the reason they could not or did not attend for ANC. High cost was a frequent complaint.

Tying in with the higher use of ANC in urban areas, in those households with their own motorised transport, and in communities with a facility providing ANC, many focus groups cited poor access to health facilities as an important barrier particularly in rural communities.

Even when they could reach a health facility, women complained that the services were poor. Health workers failed to attend, treated women badly, especially if they were poor, and demanded unofficial payments. Equipment and supplies were inadequate. This supports the quantitative finding that women from the poorest households were less likely to attend for ANC.

Reflecting the quantitative finding that more educated women were more likely to attend for ANC, another theme from the focus groups was to blame women themselves for not attending because they were uneducated, "careless", afraid of injections, or did not see the point or need of attending for ANC.

In Bauchi, many focus groups noted that husbands did not allow their wives to attend for antenatal care, sometimes because this would reflect badly on them.

Some groups also explained that a woman could have problems with her in-laws if she asked to attend for ANC.

Suggestions for how to increase the use of government ANC services largely mirrored the complaints. They wanted free care, accessible care, and good behaviour from health workers.

Focus groups in both the states called for creating awareness about the importance of ANC visits, especially among men, and young women in their first pregnancy.

Following dissemination of study findings, the Ministries of Health in both the states through Primary Health Care departments in the Local Government Authorities, deployed more health workers, including Community Health Extension Workers (CHEWs), midwives and nurses, especially in rural areas. In Bauchi, the Local Government Authorities made financial allocations to improve staff supervision and monitoring, and provide equipment and medicines to the facilities.

Also in both states, community groups of men, women and youth in the three focus Local Government Authorities who viewed the docudrama implemented local arrangements, for example to help women to avoid heavy work during pregnancy, to get adequate rest, and to attend ANC. They took local actions to create awareness about danger signs during pregnancy and child birth. They organized counselling through traditional and religious leaders to address domestic violence. In Bauchi, several community groups organized a local referral system for obstetric emergencies, including providing emergency transport and financial support. They established links with their nearest referral hospitals, to ensure they are ready to receive and deal with these emergencies.

Home visits for pregnancy surveillance in both states have encouraged male involvement, so that men support their wives during pregnancy and encourage them to attend ANC. The home visitors have informed women about what they should expect when they visit the health facility for ANC. Anecdotal evidence from the facilities suggests that women are now making requests for blood pressure measurement and urine testing during ANC visits.

As with all cross-sectional studies, we can only document associations and we do not know the direction of potential causality. In Cross River more than a fifth of the eligible women were not available at the time of the survey, mostly because they were out at work. This may have introduced a selection bias in the estimate of the use of government ANC services. It is less likely to have affected associations between different factors and the use of services. And, indeed, the analysis did not find a significant association between gainful employment and the use of ANC services.