Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey
Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey
Emmanuel Olorunleke Adewuyi 0 1
Asa Auta 1
Vishnu Khanal 1
Olasunkanmi David Bamidele 1 2
Cynthia Pomaa Akuoko 1
Kazeem Adefemi 1
Samson Joseph Tapshak 1
Yun Zhao 1
0 Statistical and Genomic Epidemiology Laboratory, Institute of Health and Biomedical Innovation, Queensland University of Technology , Brisbane , Australia , 2 School of Pharmacy and Biomedical Sciences, University of Central Lancashire , Preston , United Kingdom , 3 Nepal Development Society , Butwal , Nepal
1 Editor: Juhwan Oh, Seoul National University College of Medicine , REPUBLIC OF KOREA
2 Drug Research and Production Unit, Faculty of Pharmacy, Obafemi Awolowo University , Ile-Ife, Osun State , Nigeria , 5 School of Nursing, Faculty of Health, Queensland University of Technology , Brisbane , Australia , 6 Health and Social Relief Initiative, Ilorin , Kwara State, Nigeria, 7 Department of Obstetrics and Gynaecology, Chivar Specialist Hospital and Urology Centre LTD, Abuja, Nigeria, 8 Department of Epidemiology and Biostatistics, School of Public Health, Curtin University , Bentley Campus, Perth , Australia
Antenatal care (ANC) is a major public health intervention aimed at ensuring safe pregnancy outcomes. In Nigeria, the recommended minimum of four times ANC attendance is underutilized. This study investigates the prevalence and factors associated with underutilization of ANC services with a focus on the differences between rural and urban residences in
Data Availability Statement: The data analyzed in
this study belong to the Demographic and Health
Survey (DHS) program. The data are available and
freely accessible in the public repositories of DHS
program at https://www.dhsprogram.com/data/
available-datasets.cfm. Access to- and permission
to use the data are granted to everyone upon
request. Authors did not have any special privileges
We analyzed the 2013 Nigeria Demographic and Health Survey dataset with adjustment for
the sampling weight and the cluster design of the survey. The prevalence of underutilization
of ANC was assessed using frequency tabulation while associated factors were examined
using Chi-Square test and multivariable logistic regression analysis.
The prevalence of underutilization of ANC was 46.5% in Nigeria, 61.1% in rural residence
and 22.4% in urban residence. The North-West region had the highest prevalence of ANC
underuse in Nigeria at 69.3%, 76.6% and 44.8% for the overall, rural and urban residences
respectively. Factors associated with greater odds of ANC underuse in rural residence were
maternal non-working status, birth interval < 24 months, single birth type, not listening to
that others would not have in gaining access to the
Funding: The Queensland University of Technology
supported this paper financially by providing article
publication charge sponsorship. The fund for
publication has no role in study design, data
collection, and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
radio at all, lack of companionship to health facility and not getting money for health
services. In urban residence, mothers professing Islam, those who did not read newspaper at
all, and those who lacked health insurance, had greater odds of ANC underuse. In both rural
and urban residence, maternal and husband's education level, region of residence, wealth
index, maternal age, frequency of watching television, distance to- and permission to visit
health facility were significantly associated with ANC underuse.
Rural-urban differences exist in the use of ANC services, and to varying degrees, factors
associated with underuse of ANC in Nigeria. Interventions aimed at addressing factors
identified in this study may help to improve the utilization of ANC services both in rural and urban
Nigeria. Such interventions need to focus more on reducing socioeconomic, geographic and
regional disparities in access to ANC in Nigeria.
Promoting optimum health for women and reducing maternal and childhood mortalities have
remained a significant interest for the international community for decades [
]. This special
interest was demonstrated by the high priority accorded maternal and child health care in the
Millennium Development Goals (MDGs), and more recently, the Sustainable Development
Goals (SDGs) . Between 1990 and 2015, appreciable gains were recorded in the global
maternal-child-health care with 43.9% and 48% reduction in Maternal Mortality Ratio (MMR)
and under-five mortality rate (U5MR), respectively±thanks to the MDGs initiative [
Despite these impressive achievements, the challenge of maternal, neonatal and other
childhood mortalities remain considerably high in several developing countries with wide-ranging
disparities between and within different population groups [
Nigeria shares a disproportionately high burden of the global maternal and neonatal
mortalities, ranking as the first and the second country in the world for the highest number of
deaths among mothers and neonates, respectively [
2, 4, 5
]. These poor indices may be linked
with the low utilization of maternal healthcare services in the country [
]. Recent findings
demonstrating a correlation between maternal healthcare services utilization, MMR, and
neonatal mortality rates support this premise [
]. Specifically, studies demonstrate that ANC
attendance may protect against neonatal mortality and countries with low ANC attendance
have higher MMR [8±10]. Going by this consistent and growing body of evidence, ANC, one
of the pillars of the `safe motherhood initiative'[
], remains a major public health intervention
for preventing maternal and neonatal mortality, worldwide.
ANC, also known as `health care during pregnancy', entails periodic visits by pregnant
women to designated health centers staffed and equipped for maternity services [
World Health Organization (WHO) promotes a `focussed' ANC package which requires a
minimum of four antenatal attendance affording pregnant women the opportunity of
appropriate counselling, micronutrient supplementation (folic acid and iron), medical screening,
vaccination and preventive treatment for malaria, all aimed at ensuring safe pregnancy
outcomes [12±14]. Conditions such as hepatitis, human immunodeficiency virus, high blood
pressure and gestational diabetes are usually screened for during ANC visit [
12, 14, 15
2 / 21
Furthermore, ANC attendance assists in the early detection of high-risk pregnancies as
women with risk factors suggestive of possible obstetric complication(s) are identified through
careful history taking and appropriate medical screening for specialized and individualized
management plan(s) [
]. Increased chances of institutional delivery and hence prevention
and/or treatment of the leading causes of maternal and early neonatal mortality through timely
access to-/utilization of emergency obstetric care services are parts of the benefits of ANC
]. A recent study in Nigeria indicates that women who attended ANC had
nine to ten times increased odds of utilizing healthcare facility for childbirth in rural and
urban residences [
]. And, the greater the ANC attendance, the less likely was home delivery
]. Hence, the imperatives of promoting ANC use in the country.
Its numerous benefits notwithstanding, ANC attendance of the recommended minimum of
four times (focused ANC) [
] remains low in Nigeria [
]. The report of the 2013 Nigeria
Demographic and Health Survey (NDHS) indicates that in the five years preceding the survey,
only 51.1% of women had four or more ANC attendance in the country . This ANC
prevalence is far below the recommended target of 90% attendance [
] and comparatively lower
than the case in similar developing countries like Cameroon (62.9%) [
], Ghana (87%) [
and Peru (94.4%) [
]. Given the importance of ANC±dual roles of protecting against
maternal and neonatal mortality±evidence-based knowledge on factors associated with its low
utilization, particularly, with regards to the within-population differences is critical to the speedy
realization of SDG 3 in Nigeria. Unfortunately, studies with a major focus on this crucial
subject are limited in the country.
So far, a few nationally representative studies have assessed factors associated with the
utilization of ANC in Nigeria. For example, a previous analysis of the pooled 2013 NDHS [
reported a significant association between ANC visits and maternal age, maternal working
status, maternal education level, husband's education level, wealth index, rural-urban residence,
region of residence and religion. Similarly, a study investigating the barriers to ANC uptake in
Nigeria reported `getting money to go', `distance from health facility', `availability of transport
to the facilities' as the three leading barriers [
]. However, all these and similar studies are
limited in that they focussed primarily on the national estimates, using pooled datasets which
may mask the within-population variations such as the rural-urban differences.
Based on the analysis of the 2008 NDHS, a study has assessed the determinants of
ªurbanrural differentialsº in ANC use in Nigeria [
]. However, the title of the study could be
misleading as rural-urban stratification was not used in the multivariable analysis [
]. Indeed, the
author only adjusted for `rural-urban residence' as an independent variable, hence, the
determinants of ANC reported applied only to the overall Nigerian population in the five years
preceding the 2008 NDHS. Thus, factors associated with ANC use/underuse in rural and urban
residences in Nigeria remain unclear.
Given the notable sociocultural and socioeconomic disparities between rural and urban
communities in Nigeria [
], the present study aims to assess the rural-urban differences in the
prevalence and factors associated with ANC underuse in the country using the most recent
NDHS, 2013. This study objective agrees with the recent WHO's framework for monitoring
progress towards universal health coverage as well as the recommendation of using
disaggregated studies as an evidence-based approach to bridging equity gaps across geographic divides
2, 21, 22
]. A conceptual framework adapted from Andersen's behavioral model  guided
the study with factors tailored for the Nigerian context. Findings are expected to provide
further evidence which may inform targeted interventions aimed at improving ANC attendance
and subsequently contribute towards achieving SDG 3 in Nigeria.
3 / 21
Materials and methods
This study was based on a secondary analysis of the 2013 NDHS, a cross-sectional and
nationally representative data that are freely available online (http://www.dhsprogram.org) with
permission from ICF international, USA [
]. The Nigerian National Health Research Ethics
Committee granted ethical approval for the conduct of the survey [
]. Participants provided
informed written consent, or had it provided on their behalf by parents/guardians if they were
younger than 18 years at the time of the survey [
]. The data utilized in the present study were
fully anonymized before we accessed them with no information identifying survey
participants. No additional ethical clearance was required for the conduct of the present study.
Permission to use the data was sought and obtained from ICF International, USA.
Prior to the 2013 ±the latest and most current survey in the series±there have been four
previous editions of NDHS beginning from 1990 [
]. The 2013 NDHS was implemented by the
Nigerian Population Commission with support from many development partners including
the United Kingdom Department for International Development, the United States Agency
for International Development, and the United Nations Populations Fund [
]. The survey
aimed at providing current and up-to-date data on marriage, awareness, and use of family
planning methods, maternal and child vaccination coverage, nutritional status of women and
children, healthcare services utilization, maternal and childhood mortalities, and so on, in
]. Technical support for the survey was provided by ICF International, USA, through
the MEASURE Demographic and Health Survey program [
Sample collection in the 2013 NDHS was carried out through a stratified three-stage cluster
sampling, the design of which consisted of 904 clusters± 372 and 532 in urban and rural areas,
]. A representative sample of 40680 households (16740 in urban areas and 23940
in rural areas) was selected for the survey [
]. Interviewer-administered structured
questionnaires were utilized for data collection and three types namely women's, men's and
households' questionnaires were used [
]. Eligible to be interviewed in the survey were women aged
15 to 49 years old present in each of the selected households for at least a night prior to the
survey, as well as men of the same age category but present in the alternate households for at least
a night before the survey [
Out of the 38904 households occupied as at fieldwork time of the survey (16070 in urban
areas and 22834 in rural areas), only 38 522 were successfully interviewed (15 859 in urban
areas and 22 663 in rural areas), yielding a response rate of 99% (98.7% in urban areas and
99.3% in rural areas) [
]. A comprehensive report on the sampling procedures, settings,
questionnaires and the design of the 2013 NDHS has previously been published [
]. The data
analyzed in the present study were restricted to those of 19652 mothers with complete
information on ANC attendance/non-attendance for their most recent childbirth in the five years
preceding the 2013 survey. Where appropriate, the terms underutilization and underuse were
The main outcome variable for this study was underutilization of ANC service defined as
antenatal attendance of less than the recommended minimum of four times [
4, 24, 25
definition follows the WHO recommendation of a focused ANC model which recommends at least
four ANC attendance for pregnant women with no complication, to better optimize the
benefits of ANC services. Women with associated ill-health or those with/at risk of complication(s)
are required to make a greater number of attendance [12±14]. Antenatal services as used in the
present study are pregnancy-related care provided by skilled healthcare professionals
including doctors, nurses, midwives, and auxiliary nurses/midwives .
4 / 21
Underutilization of ANC as our outcome of interest encompasses non-attendance of
ANC as well as attendance of less than the recommended minimum of four times [
]. The ANC attendance variable captured in the 2013 NDHS (for the most recent live
births within five years leading to the survey) was dichotomized as less than four times
attendance (< 4, underutilization, coded as ª1º) and at least four times ANC attendance
( 4, utilization, coded as ª0º) for use in binary logistic regression analyses. Mothers who
responded to the question ªhow many times did you receive antenatal care during this
pregnancyº by saying `don't know' as well as those with missing information were excluded in
In line with previous studies [
], we adapted the Andersen's behavioral model  as a
conceptual framework in selecting explanatory variables for this study (Fig 1) with
consideration of the available information in the 2013 NDHS [
]. In all, twenty-three explanatory
variables, broadly classified into four: external environmental factors, predisposing factors,
enabling factors and need factors, were assessed (Fig 1). The external environmental factors
were residence (rural and urban) as well as the region of residence (categorized according to
the six geopolitical zones in Nigeria: North-Central, North-East, North-West, South-East,
South-South, and South-West).
The predisposing factors were sub-classed into two namely, socio-demographic and health
knowledge factors. The socio-demographic factors assessed included household wealth index,
a composite indicator of socioeconomic status, derived from the principal component analysis
of households' assets. The variable was re-categorized from the five levels in the 2013 NDHS to
three as follows: poor = ªpoorestº + ªpoorer,º middle = ªmiddle,º rich = ªricherº + ªrichestº[
]. Other socio-demographic factors were maternal age (< 20, 20±34, 35 years) , maternal
and husband/partner's education level (none, primary and secondary/higher) [
and husband/partner's working status (working, not working) [
], presence of co-wives (no
co-wife, other co-wives) [
] and maternal religion (Christianity, Islam, Traditional/other) [
]. Mother's final say on her own health (respondent alone, respondent and husband/partner,
husband/partner/someone else/other) , birth order (1, 2±3, 4) [
], preceding birth
interval (< 24, 24 months) [
] and birth type (singleton, multiple) were equally classified under
socio-demographic predisposing factors.
Three variables which are related to the level of media exposure±frequency of reading
newspapers/magazines, listening to radio and watching television (all categorized as: not at all, less
than once a week, and at least once a week) [
] were classified under health knowledge
factors. Enabling factors, on the other hand, comprised of variables which may encourage
health care services utilization. These included access to health insurance (yes, no) ,
distance to health facility, companionship to a health facility, getting money to pay for health
services, and getting permission to visit health facility (all categorized as: a big problem, not a big
]. Lastly, the `desire for pregnancy' (categorized as: then, later, no more) was
assessed as a need factor [
The prevalence (in %) of underuse of ANC (< 4 times ANC attendance) alongside its 95%CI
was estimated against the explanatory variables for the overall, rural and urban residences
using frequency tabulation. To assess the unadjusted association between the outcome and
explanatory variables, Chi-Square test was performed, and p-values reported by comparing the
prevalence of underuse of ANC between variable categories. The adjusted likelihood of ANC
underuse was assessed using multivariable binary logistic regression analyses accounting for
the effects of all other explanatory variables included in the models.
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Fig 1. Theoretical framework for studying factors associated with underuse of antenatal care services in Nigeria (adapted from Andersen's behavioral
The hierarchical modeling method [
] was used in the multivariable model building
process. Variables that satisfied the inclusion criterion of p < 0.20 in the Chi-Square test were
selected for inclusion in model building in line with practice in previous studies [
3, 5, 26
first model combined `external environmental factor' with the `predisposing factors' (Fig 1).
Backward elimination procedure was performed, and variables were retained for the next
6 / 21
model if they were significantly associated with underuse of ANC at 5% significance level
(p < 0.05). The second model comprised of variables retained in the first model together with
the `enabling factors'; backward elimination was similarly carried out to identify factors that
were significantly associated with the outcome variable at p < 0.05. To obtain the final
parsimonious model, variables retained in the second model were assessed against the outcome
variable with the inclusion of the `need factor'. Adjusted odds ratios (AOR), their 95%CI and
pvalues for variables retained in the final parsimonious model were reported.
The multivariable binary logistic regression analysis procedures were carried out first for
the overall Nigerian population (pooled dataset) and subsequently replicated for data
disaggregated by rural and urban residences. The backward elimination modeling was tested against
potential confounders or factors previously reported in studies so as not to miss any
statistically/clinically significant/important variable. Data management and all analyses were carried
out using the Statistical Package for Social Sciences (SPSS), version 21 released 2012 (IBM,
Armonk, NY, USA). The Complex Sample Analysis method was used in all analyses to account
for the sampling weight and the multi-stage cluster design of the 2013 NDHS .
Table 1 describes the characteristics of the sample population. A total of 19652 mothers was
included in this study of which 64.9% were rural and the rest were urban residents.
Approximately half of the mothers in the overall population did not have formal education (48.5%),
more than two thirds (68.6%) were working, nearly half (46.0%) were from poor households,
and about two-thirds were aged 20±34 years old. Only 5.2% of the mothers could decide by
themselves on issues related to their own health care (final say on own health). Following the
rural-urban disaggregation of the overall data, the percentages differ in the two residences
with urban women having better profile compared to their rural counterparts (Table 1).
Prevalence of ANC underutilization
In the overall Nigerian population, a total of 10507 (53.5%) mothers reported having at least
four ANC visits, 376 (1.8%) one-time visit, 744 (3.8%) two visits, 1363 (6.8%) three visits and
6662 (33.9%) had no antenatal care visit at all (data not shown on Tables). Furthermore, 9145
(46.5%) had attended ANC for less than the recommended minimum of four times±underuse.
Only 38.9% of rural women had four or more antenatal visits as compared to 77.6% of urban
women (Fig 2).
Table 1 shows the prevalence of underuse of ANC among Nigerian women and a
disaggregated status by rural and urban residences. The results showed that greater proportion of rural
women (61.1%; 95% CI: 58.5±63.5) underutilized ANC compared to their urban counterpart
(22.4; 95% CI: 20.0±25.1). Such difference also persisted when data was disaggregated by
ruralurban residence for the different regions of the country except for South-East region where the
prevalence of underutilization of ANC remains relatively similar (Fig 3). Furthermore, several
socioeconomic variables were significantly associated with underuse of ANC as presented in
Factors associated with ANC underutilization
The result of Chi-Square test for the unadjusted association between ANC underuse and the
various explanatory factors were equally presented in Table 1. Several factors were significantly
associated with underuse of ANC in all the residences±overall, rural and urban (unadjusted
association only). These factors included regions of residence, maternal education level,
maternal working status, husband's education level, wealth index, maternal age, maternal religion,
7 / 21
a Weighted percentages for the multistage sampling probability
Fig 2. Prevalence of ANC underuse (< 4 times) and use ( 4 times) in Nigeria.
11 / 21
Fig 3. Regional differences in the prevalence of ANC underuse (< 4 times attendance) by residences in Nigeria.
birth order, presence of co-wives, final say on own healthcare, frequency of reading newspaper,
frequency of listening to the radio, frequency of watching television, health insurance
coverage, distance to health facility, permission to visit health facility, getting money to pay at health
facility, companionship to attend facility and the desire for pregnancy.
Table 2 shows the results of the multivariable analyses for the overall, rural and urban
residences in Nigeria. For the overall population, region of residence, types of residence, maternal
education level, maternal working status, husband's education level, wealth index, maternal
age, birth interval, frequency of reading newspaper, frequency of listening to radio, frequency
of watching television, and health insurance coverage remained significantly associated with
underuse of ANC. Furthermore, distance to health facility, permission to attend facility and
companion to get to the facility were significantly associated with ANC underuse.
This study aimed at assessing the rural-urban differences in factors associated with ANC
underuse in Nigeria and Table 2 similarly elaborates on these results. In rural Nigeria, a
number of factors were associated with underuse of ANC. All the regions had greater odds of ANC
underuse compared to the South-West region except the South-East which did not attain
statistical significance. Women with no education (Adjusted odds ratio (AOR): 1.93; 95% CI:
1.11, 1.45) and those with primary education (AOR: 1.35; 1.09, 1.67) had greater odds of ANC
underuse compared to their counterparts with a secondary/higher education. Similarly,
12 / 21
Significant at P < 0.05 level.
AOR: Adjusted Odds Ratio.±Vacant spaces in the Table indicate the factor in question did not attain statistical significance at p < 0.05 in the residence.
Factors adjusted for but did not attain significance in Nigeria (overall): Husband/partner's working status, maternal religion, birth order, birth type, presence of
cowives, final say on own health, getting money for health services, desire for pregnancy.
Factors adjusted for but did not attain significance in rural Nigeria: Husband/partner's working status, maternal religion, birth order, presence of co-wives, final say
on own health, frequency of reading newspaper/magazine, access to health insurance, desire for pregnancy
Factors adjusted for but did not attain significance in urban Nigeria: Maternal working status, birth order, presence of co-wives, final say on own health, frequency of
listening to radio, getting money for health services, desire for pregnancy
women whose husband did not acquire any formal education (AOR: 2.03; 95% CI: 1.72, 2.43)
and those who were not working (AOR: 1.27; 95% CI: 1.11, 1.45) had greater odds of ANC
underuse (Table 2). The odds of ANC underuse were greater among mothers in poor
households (AOR: 2.17; 95% CI: 1.68, 2.81), as well as mothers aged 20±34 years (AOR: 1.16, 95%CI:
1.04, 1.31). Preceding birth interval <24 months (AOR: 1.26; 95% CI: 1.09, 1.46) and singleton
birth type (AOR: 1.46; 95%CI: 1.00, 2.15) were equally associated with increased odds of ANC
underuse. Lack of access to radio and television, perceived big problems with regards to
distance, permission, being accompanied and getting money to visit healthcare facility similarly
increased the odds of ANC underuse.
In urban Nigeria, some of the factors associated with underuse of ANC were comparable to
those found in rural residence (Table 2). The regional differences showed that all the regions
had lower use of four or more antenatal visits compared to the South-West. Greater odds of
ANC underuse were associated lack of maternal education (AOR: 1.44; 95% CI: 1.10, 1.87),
living in poor households (AOR: 2.05; 95% CI: 1.51, 2.79) and lack of husband's education
14 / 21
(AOR: 2.16; 95% CI: 1.68, 2.75). Similarly, mothers in the age categories <20 years (AOR: 1.75;
95% CI: 1.13, 2.70) and 20±34 year (AOR: 1.25; 95% CI: 1.03, 1.49) had greater odds of ANC
underuse compared to their counterparts in the 35-year category. Not having access to
television, perceived big problems in relation to distance, and permission to visit healthcare
facility remained significantly associated with ANC underuse (Table 2).
In contrast to the rural residence, maternal working status, birth interval, birth type, access
to radio, the problem of money and being accompanied to a health facility were not
significantly associated with underutilization of ANC in urban Nigeria. However, maternal religion
was significantly associated with ANC underuse in urban areas only and women professing
Islamic religion had 64% higher odds of underutilization than their Christian counterparts
(AOR: 1.64; 95%CI: 1.21, 2.26). Unlike in rural residence, urban mothers who reported not
reading newspaper/magazine at all (AOR: 1.74; 95%CI: 1.17, 2.59), those who did not enjoy
access to health insurance coverage (AOR: 3.41; 95%CI: 1.53, 7.58) as well as mothers who
resided in the South-East region (AOR: 1.89; 95%CI: 1.19, 3.00) had greater odds of ANC
This study assessed the prevalence and factors associated with ANC underuse in Nigeria with
an emphasis on the rural-urban differences, using the most recent nationally representative
data± 2013 NDHS. A previous study [
], based on the 2008 NDHS, has reported the
determinants of ªurban-rural differentialsº of ANC utilization in Nigeriaº. However, the determinants
of ANC reported in the study were relevant only to the overall Nigerian population since the
multivariable analysis conducted was limited to the overall data (not stratified by rural-urban
]. The factors found to be associated with ANC use in the study±maternal age,
residence, region, maternal education level, partner education level, distance to health facility,
employment status, and wealth index [
]±retained their statistical significance for the overall
Nigerian population in the present study. However, given the comprehensive selection of our
independent variables, we found several other factors, including frequency of media exposure
(newspaper, television, and radio) and health insurance coverage, to be associated with ANC
underuse in Nigeria (overall population). Moreover, we disaggregated the overall data by rural
and urban residence and compared the results from the two residences.
Our findings indicate that rural-urban differences exist in the prevalence of ANC
underuse in Nigeria. Generally, rural mothers had a greater prevalence of underuse compared to
their urban counterparts. We equally observed regional differences with the South-East and
South-West regions having the lowest prevalence in rural and urban residences, respectively.
On the other hand, the North-West region had the highest prevalence of ANC underuse both
in rural and urban residences. Following multivariable analyses, six factors±maternal working
status, birth interval, birth type, the frequency of listening to radio, getting money to pay and
companionship to healthcare facility±attained statistical significance in rural but not in urban
residence. Conversely, three factors namely, maternal religion, the frequency of reading
newspaper and health insurance coverage were significant in urban but not in rural residence. Eight
other factors±region of residence, maternal and husband/partner's education level, wealth
index, maternal age, frequency of watching television, distance to health facility and
permission to visit health facility±were consistently associated with ANC underuse in both rural and
urban residences. Thus, varying degrees of rural-urban differences in factors associated with
ANC underuse exist in Nigeria.
The findings that rural residence had significantly higher prevalence and greater odds of
ANC underuse than urban Nigeria are consistent with the report of previous studies both in
15 / 21
Nigeria and elsewhere [
16, 20, 26
]. Inequitable access to healthcare facilities/services in rural
compared to urban areas in Nigeria may explain these differences. Due to low coverage, rural
residents are generally disadvantaged in respect of access to healthcare facilities/services in
4, 32, 33
]. Where facilities exist, inaccessibility due to the poor road network, lack of
efficient transport system and distance barrier may co-exist in the residence [
possibly explain why being accompanied to health facility assumed a significant status as a risk
factor for ANC underuse in rural Nigeria. Interestingly, distance to health facility equally
attained statistical significance in all residences but with greater odds in rural areas. Traditional
beliefs, poorly equipped/staffed healthcare facilities, as well as poor socioeconomic
circumstances are some of the other factors which may contribute to underutilization of maternal
healthcare services like ANC in rural residence [
Whether in rural or urban residence, all the regions in Nigeria, except the rural South-East,
had greater odds of ANC underuse compared to the South-West (the reference category).
These findings agree with our Chi-Square test which revealed that the South-East and the
South-West regions had the lowest prevalence of ANC underuse in rural and urban residences,
respectively. The present study, therefore, lends credence to previous evidence showing better
ANC utilization in South-West and South-East regions in the country [
4, 20, 35
in socioeconomic development, educational attainment and access to healthcare facilities in
the various regions may partly explain the disparities observed in this study [
example, the South-West region relatively enjoys a greater access to education and healthcare
facilities than other regions in the country. On the other hand, the northern regions
(NorthCentral, North-East, and North-West) are educationally and socioeconomically disadvantaged
. Socioeconomic disadvantage occasioned by environmental degradation, infrastructure
deficits, and low employment level has equally been reported in the South-South region of the
]. These may contribute to low maternal healthcare services utilization in the
Furthermore, security challenges in parts of North-East, North-West (insurgency) and
South-South (militancy) regions, especially, in the rural areas may have contributed to regional
variations in this study [
]. However, in urban residence, our study indicates that mothers
professing Islamic religion had greater odds of ANC underuse compared to their Christian
counterparts. A previous study has made a similar report in respect of maternal healthcare
services utilization among Muslim mothers in Nigeria . Given that Islam is more prominent in
parts of northern regions in Nigeria [
], it is likely that the finding of low ANC utilization
among Muslim mothers contributed to the regional differences observed in this study,
especially in urban residence. Religious obligations which require that Muslim women avoid
undue exposure of their bodies have been suggested as the reason for the finding [
Financial and socioeconomic-related factors were overwhelmingly associated with ANC
underuse in this study. For instance, in both rural and urban residences, mothers classed in
the poor wealth index category had at least two-fold increased odds of ANC underuse
compared to their counterparts in rich households. These results agree with previous studies for
the overall Nigerian population [
] and highlight the negative impacts of poverty/low
socioeconomic status on ANC utilization in Nigeria. This explanation may equally be relevant
to the finding in rural residence which showed increased odds of ANC underuse in `not
working mothers' since lack of employment may translate to a low financial capability for
healthcare services. The majority of Nigerian population still live below the poverty level, hence,
bridging socioeconomic disparities in access to healthcare services should be a priority in the
For example, provision of free maternal healthcare services may improve ANC utilization
across socioeconomic divides in the country, particularly in rural Nigeria where the problem
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of getting money increased the odds of ANC underuse. Similarly, our findings suggest that
universal health insurance coverage remains an important entry point to improving ANC
attendance, especially in urban Nigeria where lack of access to health insurance increased the
odds of ANC underuse by nearly 3.5-fold. However, the results of our descriptive statistics
show that health insurance coverage was unacceptably low at 1.5%, 0.6% and 3.2% in the
overall, rural and urban residences, respectively. Future interventions need to prioritize this finding
for an improved use of ANC in Nigeria.
Furthermore, lack of maternal and husband education increased the odds of ANC underuse
in Nigeria, the rural-urban residence notwithstanding. These findings compare well with those
of studies (overall national population only) in Nigeria [
], Indonesia  and
]. However, unlike husband's education, the results for maternal education exhibited
a dose-response relationship similar to the findings of previous studies in Nigeria and
]. This result suggests that low maternal education was better than none in the
utilization of ANC services in Nigeria and may be an indication of the relative importance of
maternal education over husband's education. Besides its contribution to improved
socioeconomic status and financial capability, education may empower women to make informed and
responsible decision in matters of their wellbeing and this may contribute to increased
utilization of healthcare services including ANC attendance [
]. Similarly, better-educated
husbands would more readily understand the importance of ANC and, thus support their wives
for increased utilization of the services [
]. Lack of- or low maternal, as well as husband's
education probably explains why getting permission to visit healthcare facility remained a
significant challenge in all residences in Nigeria.
The contribution of media exposure to the odds of ANC underuse was equally highlighted
in this study. Based on our findings, not watching television at all contributed to increased
odds of ANC underuse in all residences in Nigeria. On the other, none or low frequency of
listening to radio was significantly associated with higher odds of ANC underuse in rural
residence while none or low frequency or reading newspapers was a risk factor in urban residence.
These findings are similar to those of a study in Nepal [
], and they underscore the important
role of media exposure in healthcare services utilization. Second, the results indicate that some
media may be more effective than others in reaching different population groups in Nigeria
for ANC utilization. This observation may find relevance in designing appropriate behavior
change communication models [
] for improved uptake of not only ANC but other
healthcare services in Nigeria. For, instance, health information through the newspaper would not
be effective in rural residence as found in this study. Thus, it may be appropriate, for instance,
to encourage rural women to frequently listen to radio for a better exposure to healthcare
Strengths and limitations
The use of recent nationally representative datasets, high response rate and rural-urban
disaggregation of data are some of the strengths of this study. Hence, findings are current and
generalizable. Also, given the large sample size for the survey, data disaggregation does not
undermine generalizability. Other notable strengths include low missing data and application
of complex samples statistics in data analysis to adjust for the sample weight and cluster design
of the dataset used. The use of a well-regarded behavioral model as a conceptual framework
means relevant independent variables were comprehensively assessed in this study. To the best
of our knowledge, this is the first nationally representative study to comprehensively assess
rural-urban differences in the prevalence and factors associated with ANC underuse in
Nigeria. Nevertheless, a few limitations need to be considered when the results of this study are
17 / 21
being interpreted. First, a causal relationship could not be estimated owing to the
cross-sectional design of the survey. Second, the dataset analyzed in this study were self-reported,
collected retrospectively and so prone to social desirability and recall biases.
This study assessed the prevalence and factors associated with ANC underuse in Nigeria with a
focus on the rural-urban differences. Findings indicate that the prevalence of ANC underuse
differs between rural and urban residences in Nigeria, and rural residence had significantly
higher prevalence. Regional differences were equally observed in both residences with the
South-East and South-West regions having the lowest prevalence in rural and urban
residences, respectively. On the other hand, the North-West region had the highest prevalence of
ANC underuse, rural-urban residence notwithstanding. Factors associated with ANC
underuse differ to varying degrees in both residences. The need to address the rural-urban as well as
regional disparities in ANC use was highlighted in this study. Generally, rural residence,
northern regions as well as the South-South region of the country require a greater priority for
increased ANC utilization. Specifically, however, the need for targeted interventions for
women professing Islamic religion (especially in urban residence), uneducated mothers and
fathers (in all residences) as well as poor mothers (in all residences) was revealed.
Practical and implementable interventions such as equitable access to healthcare facilities
need to be pursued in rural Nigeria. Healthcare/ANC facilities would need to be sited within
manageable distance for ease of accessibility. Also, availability of a universal health insurance
coverage (particularly, in urban residence), as well as the provision of free ANC services
(especially in rural residence) may contribute in addressing financial constraints associated with
ANC attendance in Nigeria. Intervention efforts focused on improved access to-/knowledge of
family planning services in rural residence may prove beneficial in addressing the challenge of
a short interval between births, and subsequently, ANC underuse. Also, appropriate selection
of media services for health promotion purposes based on findings in this study should form
part of a holistic approach to addressing the challenge of ANC underuse in Nigeria. Lastly, as
part of a long-term strategy, education of at least a secondary school level needs to be
promoted in all residences in Nigeria.
We gratefully appreciate ICF International, USA, for providing the NDHS data for this study.
Also, authors thank Mary Ishaku Adewuyi for her generous support in proofreading this
Conceptualization: Emmanuel Olorunleke Adewuyi, Asa Auta, Vishnu Khanal.
Data curation: Emmanuel Olorunleke Adewuyi, Yun Zhao.
Formal analysis: Emmanuel Olorunleke Adewuyi.
Funding acquisition: Emmanuel Olorunleke Adewuyi.
Methodology: Emmanuel Olorunleke Adewuyi, Asa Auta, Vishnu Khanal, Yun Zhao.
Project administration: Emmanuel Olorunleke Adewuyi.
Resources: Emmanuel Olorunleke Adewuyi.
Software: Emmanuel Olorunleke Adewuyi, Kazeem Adefemi.
18 / 21
Supervision: Yun Zhao.
Validation: Emmanuel Olorunleke Adewuyi.
Writing ± original draft: Emmanuel Olorunleke Adewuyi, Asa Auta, Vishnu Khanal,
Olasunkanmi David Bamidele, Cynthia Pomaa Akuoko, Kazeem Adefemi, Samson Joseph
Writing ± review & editing: Emmanuel Olorunleke Adewuyi, Asa Auta, Vishnu Khanal,
Olasunkanmi David Bamidele, Cynthia Pomaa Akuoko, Kazeem Adefemi, Samson Joseph
Tapshak, Yun Zhao.
19 / 21
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