Abstract

Background: In Nigeria and other developing countries, there are still recorded high cases of maternal and perinatal mortality rates which can be attributed to the general under utilization of antenatal care (ANC) services which varies across variables. Antenatal care still remains the proven approach targeted to improving the quality and efficacy of ANC and also improving the overall health outcome of mother and child. The new model recommends a minimum of 8 contacts during the entire course of a woman’s pregnancy in order to reduce drastically incidences of maternal and perinatal mortality and to also enhance the woman’s experience of care during pregnancy

Objective: This study presented an overview of Antenatal Care Service Utilization Studies and Services in Nigeria and generated information for intervention and policy making.

Methods: This study reviewed an overview of antenatal care services and its utilization in Nigeria imploring the use of a narrative review style literature writing. The literature search was conducted on computerized databases. Search terms were used singly, in combination, and truncation to select and synthesize articles. The studies selected included those written in the English Language that was carried out in Nigeria with clear study design and properly stated year of publication which fell within the stated years of 1990 to 2020. The data obtained were subjected to descriptive statistics of frequency and percentage and was also subjected to comparative assessment using the Oxford and Scottish Benchmarks for Study Standard.

Results: A total of 54 articles met the criteria and were used for the study. The highest incidence of the articles selected were studied Nation-wide (40.74%). This was followed by the southwest (27.78%). South-south and southeast had the same number of articles selected (9.26%), while the north-central had the highest number (7.41%)of articles sited in the north, with north-east and north-west being (3.70%) and (1.85%) respectively. Only one article on antenatal care services and its utilization was cited before the year 2000 (1.85%) while the highest number of studies (79.63%) which were conducted out between 2011 and 2020. The studies were found to fall within the lower half of the Oxford and Scottish benchmarks for the hierarchy of studies and study standards.

Conclusion: Antenatal Care service utilization in Nigeria are still at their teething stage. Most of the incidence of the studies conducted were nation-wide and in southwest. The leading study design carried out were cross-sectional descriptive surveys which fell within the lower half of two standard benchmarks (Oxford and Scottish) for the hierarchy of studies.

Keywords: antenatal care; services; service utilization; nigeria; narrative review; maternal Health; health survey.

Abbreviations: ANC: Antenatal Care; NDHS: Nigeria Demographic and Health Survey; NARHS: National HIV & AIDS and Reproductive Health Survey; WHO: World Health Organization; FANC: Focused Antenatal Care; PHC: Primary Health Centre; LGA: Local Government Area; MDG: Millenium Development Goal; SDG: Sustainable Development Goal.

Citation: Triumph NA, Onyebuchi OB. Evaluation of antenatal care utilization studies in Nigeria from 1990-2020: A narrative review. J Clin Images Med Case Rep. 2021; 2(6): 1509.

Introduction

It is no news that countries in the Sub-Saharan region possess a high number of maternal and infant mortality as compared with most other developed countries of the world. Therefore, the Millennium Development Goal (MDG) and Sustainable Development Goal (SDG) gave a great deal of emphasis to health and well-being of all, especially as concerns infants and pregnant mothers. The 5th MDG was also targeted at promoting maternal health aimed at reducing maternal mortality by three quarters and improving universal access to reproductive health. In like manner, the 3rd SDG was aimed at global reduction of maternal mortality ratio to about less than 70 per 100,000 live births and also a great decline in neonatal mortality and under-5 mortalities to 12 and 25 per 1000 live births respectively in all countries. Utilization coupled with early commencement and achieving the adequate number of times of Antenatal Care (ANC) is therefore a key and proven way to achieving these goals [1].

Antenatal Care (ANC) is therefore a clinical assessment carried out on mother and fetus during pregnancy to ensure that only the best possible health outcome is achieved both for the mother and the unborn child. It is very crucial and imperative for the health of both the mother and the developing unborn baby during pregnancy. The activities conducted during ANC is required component of maternal health as it deals with identifying complications and any possible danger signs during the entire period of a woman’s pregnancy [2]. It’s activities exposes the pregnant mothers to counselling and relevant educational tips about their own health and also care of their unborn children.

Focused Antenatal care was designed to be a goal and clientoriented service which necessitated at least four ANC visits for the pregnant mothers during each pregnancy. WHO requires that pregnant women should have a minimum of eight ANC as opposed four visits so as to efficiently identify complications immediately as they occur and also significantly reduce perinatal and maternal mortality. However, despite the availability and importance of ANC services, 36% of pregnant women worldwide still visit antenatal clinic less than four times during their entire length of pregnancy whereas some don’t even attend at all. Across sub-Saharan only about 71 percent of the pregnant mothers’ population attend ANC at least once, however, only about 44% of them attend ANC clinic four or more times. The Nigeria Demographic Health Survey (NDHS) 2013 accounted that only about 61% of women attended ANC during pregnancy, showing a marginal increase of 3% as compared record from the NDHS 2008 [3].

WHO made a latest recommendation, the 2016 ANC Model, which served as an intervention package targeted at improving the quality and efficacy of ANC and also improving the overall health outcome of mother and child. The new model recommends a minimum of 8 contacts during the entire course of a woman’s pregnancy in order to reduce drastically incidences of maternal and perinatal mortality and to also enhance the woman’s experience of care during pregnancy. In Nigeria, only 5 out of 10 women had about 4 or more ANC during their entire course of pregnancy thus resulting to lack of progress in achieving reduction in maternal and child mortality [4].

In Nigeria and other developing countries, there are still recorded high cases of maternal and perinatal mortality rates which can be attributed to the general underutilization of antenatal care services. About 600,000 women were recorded dead due to pregnancy related problems globally per year, of which a total number of 52,900 of the total sum of maternal deaths are recorded in Nigeria. This is approximately 10% of the maternal deaths globally whereas Nigeria only sums up to about 2% of the world’s entire population. Consequently, in Nigeria, woman chance of dying from pregnancy and child delivery is 1 in 13. The maternal mortality in Nigeria is seen to be approximated to 800/100,000 live births associated with significantly distinct urban-rural variations; 351/100,000 live births postulated for urban inhabitants and 828/100,000 for rural inhabitants. This variation is extensively large as compared with some developed countries like Sweden, Finland etc [5]. This study presented an overview of Antenatal Care Service Utilization studies and Services in Nigeria and generated information for intervention and policy making.

Methods

Study area: The study covered antenatal care utilization studies carried out in Nigeria.

Review question: What is the trend and dynamics of antenatal care utilization in Nigeria?

Study population and type of studies included: The search was carried out on PubMed and Google Scholar. Manual search was done for studies that met the inclusion criteria. This ensured retrieval of relevant studies while focusing on the study objectives.

Eligibility criteria

• Studies published in English language.
• Peer-reviewed papers were eligible for inclusion.
• Antenatal care utilization studies conducted in Nigeria irrespective of the region.
• Studies with defined protocol and study design either experimental or non-experimental.
• Studies with no conflict of interest stated.
• Studies that provided other information that may help to understand antenatal care utilization.
• Studies with clearly stated and defined research design.

Ineligibility criteria

• Studies without clearly defined period, duration, sample size and location were discarded
• Studies with methodological flaws
• Studies with incomplete data.

Study design: The study was a narrative overview of antenatal care utilization studies in Nigeria.

Risk of bias: The included studies were assessed for subjects and sampling selection bias, reporting bias before selection.

Condition and domain studied: Antenatal Care studies and articles that described antenatal care utilization activities in Nigeria.

Information source: Search was conducted using Google Scholar and PubMed. Data extraction was done in accordance with the standard reporting protocol for narrative reviews [6].

Data items and summary measures: The data obtained were sought for study location, design, sample size, year of publication, inclusion criteria, exclusion criteria, year of publication, study instrument, title of publication. Articles that met the inclusion criteria irrespective of their year of publication were selected.

Context: The study covered antenatal care utilization studies carried out in Nigeria from 1990 to 2020.

Articles search process: The figure below (Figure 1) represents a graphical illustration of how the search was conducted. The keywords related to the title of the study was used for the search. PubMed and Google Scholar were used to search for studies and articles on antenatal care utilization in Nigeria published between 1990 and 2020. Additional words found appropriate and relevant to the title and objective of the study were utilized. A total of 877 articles were obtained, 105 came from PubMed and 772 articles from Goggle Scholar. These articles were assessed for eligibility based on the inclusion criteria.

Study period and duration: The study lasted from July to August, 2021 and covered peer reviewed articles published from January 1990 to December, 2020.

Ethical approval: Ethical approval is not applicable here. However, only studies with ethical approval were included and utilized in the review process.

Data analysis: Data was summarized with descriptive statistics.

Study articles selection process: A total of 877 articles were obtained, 105 came from PubMed and 772 articles from Goggle Scholar. These articles were assessed for eligibility based on the inclusion criteria. Overall, 482 studies which felled outside the scope of pharmaceutical care were discarded giving rise to 395 articles. On further screening, 256 articles with invalid and incomplete study design were eliminated, and another 85 articles with incomplete follow up data which gave rise to 54 studies used for the review.

Data extraction instrument, pilot testing, and data extraction process

Data Extraction design was adapted from a similar study carried out in Nigeria by Ogbonna et al (2019) [7]. Data was extracted by careful consideration of the articles, elimination of irrelevant or incomplete ones that did not meet the study objective and criteria. The remaining data were analyzed and pilot tested. Five articles were used for the pilot test and they were not included in the study. Further modifications such as the arrangement of the date items logically and designing of the sheet into an appropriate table format were made to obtain the final instrument. The instrument was approved by an independent assessor after critiquing it by applying it to two independent studies before being used for the data collection.

Discussion

An overview of antenatal care service utilization in Nigeria

Antenatal are first evolved from the European countries but it was not evidenced based. This was the Traditional ANC model which was developed in the early 1900s. The model only emphasized on the number and frequency of ANC visits which recommended approximately 12 clinic visits, if the woman began ANC in the first trimester. This involved once a month for the first six months, once every two to three weeks for the next two months and once a week until birth. This model was later adapted to Focus ANC by WHO which was developed in 2002. The Focus ANC was goal-oriented in its approach to delivering evidence-based interventions at four critical times during pregnancy. This approach greatly achieved an increase in ANC in the low-and middle-income countries. FANC was later shown not to be promote positive outcomes during pregnancy and perinatal death reduction, therefore leading to a development of a newer model in 2016 by WHO. This model emphasized contact rather than visit and recommended at total number of 8 contacts instead of the ongoing 4-visits and the provision of quality at each contact [59].

Over the years, there has been considerably large underutilization of antenatal care services in Nigeria. This underutilization though varies from region to region likewise state to state. There is also sparse variation between the old and young, rural and urban communities. There have been consistent records from various studies revealing that age, parity and level of education has great effects on ANC utilization as younger women aged below 20 years utilize ANC services much better than older women, Women with secondary school were also found to utilize ANC, have more clinic visits 2-3 times better than women with primary or no education at all [48].Observational studies were best fit in accessing and analyzing the utilization differentials across various variables in Nigeria this corresponding to distribution of the studies showing a higher incidence of non-experimental studies in the country. This could also be as a result of the relative ease in the conduct of an observational study than experimental studies. Also, due to the reduced cost, manpower and time employed for an experimental study. Most of the studies cited in the work were also carried out within the last two decades as shown in table 1 and 5, recording 18.52% within the decade of 2001 to 2010 and the last following decade (2011-2020) recording 79.63% while the decade of 1999-2000 recording one cited work (1.85%). This is largely owing to the fact than the concept of ANC first evolved from the European countries and was later gradually adapted by the Nigerian government when they adhered to WHO’s focused/goal-oriented model which was introduced in 2002 and has furthermore integrated into the Federal Ministry of Health System as an orientation package for Health Care Providers [31].

Table 1: Evidence-based table

Description of the ANC utilization and the extent and nature of work done in Nigeria

Table 2 revealed the regional distribution of the articles and the study focus of each region. It showed that the highest number of studies were done Nation-wide (40.74%) followed by the South-west and region (27.78%) of the country. South-south and South-east had an equal distribution (9.26%). The theme of the works conducted nation-wide comprised of Factors affecting ANC utilization, Satisfaction, Barriers and Timing while that of the south-west focused more on Factors of ANC utilization, Assessment of quality and Reasons for late ANC. The studies in the south-south and South-east focused ANC utilization and Reasons for late initiation.

Table 2: Focus on studies on Antenatal Care Utilization in Nigeria according to geo-political zone distribution.

Most of the works were nation-wide because it was relatively easier to carry out population cross-sectional study from already recorded databases mostly obtained from the Nigeria Demographic and Health Survey data as they served as already provisions for conducting pooled analysis. The Nation-wide studies also provided for comparative analysis between regions, states and more also within year. The few studies sited in the northern region mainly focused on Utilization of ANC and Knowledge. Among the Northern region, North Central posed to have higher works (7.41%) carried out as opposed North-east (3.70%) and North-west (1.85%).

Description of ANC activities and comparisons of the studies to the oxford and Scottish benchmarks for the hierarchy of clinical

As shown by Table 4 on the hierarchy of studies, observational studies had all the number of records 100%. Other types of the studies in the hierarchy had no record as observational studies presumably were best fit in accessing and analyzing the utilization differentials across various variables.

Table 4: Assessment of Antenatal Care Utilization studies on in Nigeria based on the Scottish Intercollegiate Guidelines Network for hierarchy of Study Type [58].

Most of the studies cited were surveys carried out using questionnaires as the instrument of study. Although the questionnaires were used directly on the respondents or they were used on the records from the Population Data. A few of the studies involved non-ANC users but most of them were focused on pregnant women. As portrayed by Table 3 on Evidence-based Medicine Evidence level, Case series, poor quality cohort, and case- control studies have the highest score of 88.89% while ecological studies had 11.11% leaving the rest of the study with 0% score. This shows that ANC service utilization activities in Nigeria is still at its primary level.

Table 3: Assessment of Studies on Antenatal Care Utilization in Nigeria based on Oxford Center for Evidence-Based Medicine’s Levels of Evidence from Highest to Lowest [57].

Table 5: Periodic Distribution of Antenatal Care Utilization studies in Nigeria

Conclusion

Many of the articles cited were studies carried out on pregnant women within the reproductive age [15-49]. All the studies conducted were all observational. The distribution of the studies recorded higher incidence of the study conducted nationwide as compared to the various other regions with south-west topping the other regions. The studies fell short of the Oxford and Scottish benchmarks for the hierarchy of studies showing that the Antenatal Care Utilization activities in Nigeria is at its primary level.

Limitations

The possibility of omission due to search and search terms limitations. Some of the studies sited may have some level of bias which escaped elimination which could have an impact on the outcome of the study. The method of presenting tables and data in the present study was purposively chosen for simplicity and clarity even though they could be better presentation formats.

Highlights (Learning points)

1. No narrative review article was found which reviewed the ANC in Nigeria over the past four decades.
2. The study articles on ANC cited since 2020 fell below the higher upper half of the Hierarchy of Study Type Standard Benchmark of Oxford and Scottish benchmarks.
3. Majority of the studies on ANC in Nigeria were carried out nationwide and in the south-western region.
4. The theme of the works conducted nation-wide comprised of factors affecting ANC utilization, satisfaction, barriers and timing while that of the south-west focused more on factors of ANC utilization, assessment of quality and reasons for late ANC. The studies in the south-south and South-east focused ANC utilization and Reasons for late initiation. The few studies sited in the northern region mainly focused on Utilization of ANC and Knowledge.
5. This work is a narrative overview of ANC service utilization in Nigeria. It reviewed a general overview of the ANC activities, revealed the studies conducted on the subject matter, showing the level of the work done and gave a comparison of the available studies with some standard benchmarks for the hierarchy of study type. It also gave recommendations and provided documented information for intervention.

Declarations

Conflict of interest: The authors have none to declare.
Grant/sponsorship: None was obtained.

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