Both patients and physicians influence levels of utilization, but at different points in the healthcare continuum and for different types of services. Patients are likely to initiate first contact care, and physicians are important in affecting follow-up visits, procedures performed, and hospital admission rates. Antenatal care can bring numerous benefits to mothers and their infants, and it is more likely to be effective if a woman initiates ANC visits early and proceeds to the continuous care throughout the pregnancy. Factors of demography, socio-economic and socio-cultural importance play a key role in influencing the maternal take-up of ANC services.

Moreover, mothers’ perceptions of the available services and satisfaction with the services can be recognized as predictors of healthcare utilization and medical compliance.

The purpose of this study was to identify the determinants of pregnant mothers in Esan West Local Government Area, Nigeria using antenatal care services. A cross-sectional case study aimed at evaluating the level of use of antenatal care in a selected public hospital and exploring the correlations between general characteristics, performance of prenatal care, satisfaction, and maternal uptake of pregnancy care. Using a questionnaire and surveys, information was obtained from 260 pregnant women visiting the hospital. Descriptive statistics and chi-square tests were used for data analysis with the level of significant set at p<0.05. The results showed that fifty-seven percent of expectant mothers took their first antenatal care visits in their first trimester, and the total number of visits they made was four or more. The total score of QPCQ (4.03) indicated the pregnant women graded high quality on the antenatal care they received. Among the six subscales, the mean score of anticipatory guidance was the lowest with the value of 3.52, which indicated that the pregnant women were not satisfied with the provided guidance and knowledge to make decision and plan for their pregnancy and delivery. Close to half of the informants were pleased with antenatal care and overall its healthcare (49 percent).

One of the productive results of antenatal care use was good results in evaluating the knowledge of prenatal care and services for pregnancy. Significant association between antenatal care use and Maternal age, parity, academic level of both respondents and their spouses, history of complication in previous pregnancy, perception, satisfaction. In order to increase the use of antenatal care services, healthcare authorities should enhance the quality of services related to pregnancy through offering patient-centered care, increasing acceptability, availability, accountability, and reliability of treatment, enhancing input from patients or consumers as feedbacks with the support of technology, communication and cooperation with other stakeholders, and raising community participation.

Key words: Antenatal care service, Healthcare Quality, Healthcare Utilization, Nigeria, Public Hospitals, Satisfaction.

1.1 Research background
This chapter introduces the concepts of maternal mortality, and interventions needed to help prevent maternal death.

1.1.1. Maternal mortality
Overall, global maternal mortality fell dramatically from 1990 to 2015, with the figure dropping about 44 percent, and also the lifetime risk of deaths of mothers shifting from 1 out of 73 to 1 in 180 (UNICEF data, 2017). “Maternal mortality” refers to “the death of a woman during her pregnancy period or within 42 days after termination of pregnancy with any related or provoked cause from the pregnancy or its management but not from unforeseen and unintentional causes, regardless of the duration and site of the pregnancy” (WHO, 2015).

Maternal deaths persists as a major challenging situation, with the value of around 830 women dying every day from preventable causes of pregnancy and delivery, and 99% of this occurs in developing countries, especially women living in rural areas and poorer communities (WHO, 2018). According to WHO, the deaths of mothers are brought about by complications during and following pregnancy and childbirth. The major complications accounting for almost 75% of maternal deaths are severe bleeding after birth, high blood pressure during pregnancy, obstructed labor, and unsafe abortion and delivery (WHO, 2018).

The momentum of political commitment to universal health coverage is now the greatest ever (Tracking Universal Health Coverage: 2017 Global Monitoring Report, 2017). In 2015, at the end of the Millennium Development Goal (MDG) era, 17 Sustainable Development Goals (SDGs) were set and targeted to be achieved by 2030 by the leaders from 193 countries.

SDG 3.1 is set as "Reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030" (United Nations, n.d.)

1.1.2. Interventions to prevent maternal deaths
Almost all maternal deaths can be prevented through timely interventions and treatment of maternal health services. Maternal health services are deemed "essential" in many countries, including Nigeria (PSI, 2017). It is obvious that every pregnant woman has a right to access basic services for pregnancy, namely, antenatal care (ANC), postnatal care (PNC) and delivery services. Low utilization of maternal health services would likely lead to a higher maternal mortality ratio (MMR), which has been widely used as a development indicator (The World Bank, Data, 2017).

1.1.3. Antenatal care (ANC)
Among health services, antenatal care is the point of entry for pregnant mothers to the healthcare system and is an important determinant of a continuum of care for safe delivery. Through this program, pregnant women will be aided in establishing a suitable birth plan and other programs such as vaccination, supplementation, and managing nutritional deficiencies. Moreover, it enables not only identification of potential risks of pregnancy or delivery threatening lives of mother and child but also provision of prompt treatment by health professionals (WHO, The World Health Report, 2005). Therefore, ANC can be regarded as one of the preventive healthcare services and a well-timed and adequate utilization of it can reduce maternal and child morbidity and mortality (Abou-Zahr, Wardlaw, 2003).

It is recommended that ANC be received as early as possible and that it be continued throughout the pregnancy with at least eight ANC contacts: first ANC contact should take place in the first trimester, two contacts in the second trimester and five contacts in the third trimester (WHO recommendations on antenatal care for positive pregnancy, 2016). Utilization of ANC can be measured by the timing of initiation of care and number of actual visits according to 1994, Kotelchuck's Adequacy of Prenatal Care Utilization (APNCU) index, which is a standard and the most widely used index for ANC utilization (Adequacy of Initiation of Prenatal Care & Adequacy of Received Services (once prenatal care has begun)).

Effective utilization and compliance with interventions are influenced by the perception and satisfaction with ANC services (Erci & Ivanov, 2004). Additionally, perceptions of ANC services by pregnant women crucially impacts on their utilization and continuity of use. (Saxena, Chandhiok, Dhillon, & Kambo, 2006). If they are aware of the fact that ANC services offer fundamental care components, such as screening and diagnosis, education, treatment, and referral to specialist care, they would have the willingness to comply with the services. In addition, patients who are satisfied are willing to return and suggest healthcare services to others

- Satisfaction with care quality

- Satisfaction with access to care

1.2. Problem statement
In Nigeria, maternal mortality ratio (MMR) is relatively high, 282 per 100,000 live-births (range of 157 to 357) and is ranked second highest in ASEAN region (Thematic Report on Maternal Mortality; Census Report Volume 4C, 2016). Maternal health services remain underutilized in Nigeria. While WHO recommends at least four antenatal care (ANC) visits for a pregnancy without complications (WHO recommendations on antenatal care for a positive pregnancy experience, 2016), the ANC coverage with skilled personnel for one or more ANC visits during last pregnancy in 2015-2016 Nigeria was 81%; however, the coverage with four or more ANC visits was only 59%, and only 40% of women took their first ANC visit during the first trimester of pregnancy as recommended (Nigeria Demographic and Health Survey 2015-1016). All these data indicate that utilization of ANC services is low in Nigeria.

Bad health-seeking behavior, limited or difficulty in access to health facilities and poorly structured health systems, which are interrelated with cultural norms, and societal influence are important factors to understand and address in order to encourage the use of ANC services by pregnant women for the well-beings of both mothers and infants (WHO, 2006).

To date, there are a limited number of studies related to the use of ANC services by pregnant women in Nigeria although there are studies conducted on the utilization of maternal health services in Nigeria. Thin Zaw et al. (2012) and Sein (2012) investigated maternal health services, only with youths, in the peri-urban area of Mandalay City and in Edo state region, respectively.

It is therefore important to understand the factors that influence pregnant women in taking ANC visits and to compare the drivers and deterrents for them in ANC uptake. The results of this study can also deliver profitable information to the Health Ministry and other authorities to bring up the appropriate actions to support effective ANC services for pregnant mothers.

1.3. Research question(s)
The main research question is:

What is the status of utilization of antenatal care services by pregnant women at public health facilities in Esan West Local Government Area?

1.3.1. Sub-questions:

• Do sociodemographic factors have an impact on ANC utilization?

• Is ANC uptake affected by maternal age?

• Do women’s education and occupation influence their ANC visits?

• Is pregnant women’s ANC visit affected by her husband’s education and occupation?

• Does women’s intention of pregnancy affect their ANC uptake?

• Does support from pregnant women’s family members increase their ANC visits?

• Does the cost (transportation and necessary test) negatively impact women’s ANC visits?

• Does income of her household affect her uptake of ANC?

• What is the women’s perception on provided ANC services?

• How do women evaluate the quality of care received?

• To what extent do women know about ANC services?

• Do their perceptions have an effect on the utilization?

• To what extent are they satisfied with the provided antenatal care services?

• Is their satisfaction level related to their utilization status?

1.4. Hypotheses
1) There is an association between sociodemographic characteristics and utilization of antenatal care (timely visits and frequency)

2) A positive association exists between the level of satisfaction and the uptake of required prenatal care visits

3) There is a positive association between the use of antenatal care and awareness and knowledge about its services

1.5. Research Objectives
• To examine the factors associated with the use of prenatal care at public health facility in Esan West Local Government Area by mothers

• To determine the level of mothers ' perception of the services available in terms of quality and knowledge, and their satisfaction level with the provided antenatal services

• To provide a better understanding of the determinants of antenatal care utilization by mothers in Esan West Local Government Area

• To contribute to an understanding of the needed interventions for improving antenatal care utilization in Nigeria

1.6 Significance of the study
Several empirical studies have identified the factors affecting the uptake of ANC: demographic, socio-economic and quality of ANC services. Nonetheless, few types of research have been conducted concerning ANC utilization in Nigeria.

This study aims to identify the association between the utilization of ANC services with:

• The perceptions of women (knowledge and awareness) of the ANC services available

• Their satisfaction with the services received

• The impact of socio-economic, demographic factors

The results from this study are expected to make a contribution to an understanding of the interventions needed for improving ANC utilization.

1.7 Limitations and potential problems
- The respondents or cases of this study were selected with specific characteristics of interest in order to reflect their experiences of their previous visits. Some of the interesting information from the first-time visitors was not collected.

- As the study respondents were in their last trimester, it was really difficult to arrange focus group discussion (FGDs) by gathering some of them. Therefore, FGDs was not carried out in this study.

- There might be some recall bias as this study examine the women’s experiences in their previous antenatal care visits.

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