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Barriers to Utilization of Antenatal Care Interventions among Pregnant Women Attending Primary Health Care Centres in Kano, Nigeria

Background: Knowledge of Ante-Natal Care interventions (ANC) and removal of barriers associated with access to the interventions can significantly reduce the burden of maternal, neonatal, and infant morbidity and mortality in Sub-Saharan Africa. Objective: This study assessed the knowledge and barriers to ANC interventions among pregnant women attending PHC in Kano. Methods: Descriptive cross-sectional study design was used to study 383 pregnant women attending ANC in primary health care centers in Kano metropolis using a three-staged sampling technique. Data was collected using interviewer administered semi-structured questionnaire and analyzed at univariate, bivariate and multivariate levels using IBM SPSS Statistics for Windows, version 20. Results: Out of the 383 questionnaires distributed 374 were retrieved and analyzed, giving a response rate of (97.7%). The mean age of respondents was 25.7±4.8years. The majority of the pregnant women studied (60.0%) were greater than 24 years of age with most of the respondents having formal education (96.8%) and married pregnant women constituted most (89.0%) of the respondents. The maximum knowledge score was 39 and the minimum was 10 with a mean of 24.8±5.8. Many pregnant women (97.0%) had satisfactory knowledge of ANC interventions. Age greater than 24 years (p<0.001), employment (p<0.001), gestational age between 4-6 months (p<0.001), urban residence (p=0.02) were found to be significantly associated with satisfactory knowledge. Age greater than 24 years {AOR=2.0, 95%CI= (1.1-3.7)}, Gestational age ranging between 4-6 months {AOR=0.5, 95%CI= (0.3-0.8)}, and urban residence {AOR=2.0, 95%CI= (1.1-3.7)} were found to be independent predictors of knowledge of ANC interventions. Variable barriers to using various interventions were reported. The barrier to using iron and folic acid reported by about a half of the respondents (50.0%) was forgetting to use the tablets, the financial capacity to transport self to the facility was reported to serve as a barrier to using Long Lasting Insecticides Treated Nets by about one-fourth (25.0%) of the pregnant women. Similarly, up to one-fourth (25.0%) had fear of side effects as the barrier to using IPT(sulphadoxine/pyrimethamine). Barrier to using some health education interventions was reported to be due to rejection by the spouse. Conclusion: Pregnant women were knowledgeable on the available ANC interventions but are faced with many barriers to accessing them. The government should, therefore, formulate policies directed to addressing the identified barriers.


Introduction
The health of mothers and children are some of the important factors that determine global and national wellbeing. This because every individual, family and community is at some point involved in pregnancy and the success of childbirth. 1 Nigeria is second to India in terms of the absolute number of maternal deaths and regrettably, despite abundant resources, contributes more than 10% of all global maternal deaths. 1 The reasons for high maternal mortality ratio are multipronged and complex including but not limited to access, and utilization of maternal health services in various parts of the country regarded as main causes. Reduction of maternal mortality has long been a global concern and priority as enunciated by the Millennium Development Goals (MDG) framework, the Global Strategy for Women's and Children's Health, and the Sustainable Development Goals. To further advance the reduction of maternal mortality in Nigeria, factors influencing the nonutilization of maternal health services need to be addressed [1][2][3] . Nigerian government specifically recommends Primary Health Care as the entry point to the health care system to generate universal health coverage for all citizens. 2 Little empirical evidence exists from primary sources on the reasons why women use or do not use primary healthcare facilities in Nigeria for maternal health care and the individual-level predictors of use or nonuse. 1,2 Analyses of the utilization of primary health care facilities in Nigeria have been limited in their focus such as the description of interventions, quality of care and patients or community satisfaction, knowledge, adequacy of resources and adequacy of antenatal care. 2 The effect of user fees protects the poor by reducing catastrophic out of pocket expenditure. Some developing countries with high MMR have adopted free maternal health care policy at various levels, as an intervention intended to improve maternal health. 4 To attain an optimum level of health during pregnancy and the best possible maternal and neonatal health outcomes, effective interventions need to be delivered during the preconception period and throughout pregnancy. In recent years, there has been increased awareness regarding the importance of preconception period and efforts have been made to increase knowledge and promote health right from childhood and adolescence onwards. Research has also established evidence linking quality preconception interventions with improved maternal, perinatal and neonatal health outcomes. 5 A study reported that pregnant women quit antenatal care to deliver at home mainly due to maternity staff attitude and presence of male healthcare workers during delivery and concluded that, pregnant women are aware of the importance of antenatal care and, do deliver at home due to behavioral, socio-cultural and religious preferences. 6 Low antenatal attendance was reported to be due to inadequate knowledge about the ideal time of starting ANC, understaffed clinic, traditional beliefs and cultural practices were reported to affect antenatal attendance. Other factors identified were socio-cultural practices such as afraid of witchcraft, long distances and need for material support from family members. 7 There is a paucity of literature in areas that assessed the knowledge of pregnant women on the interventions provided to them during routine ANC visits and barriers associated with accessing the services provided for pregnant women. This study, therefore, assessed the knowledge of ANC interventions, barriers and enablers to using the interventions among pregnant women attending ANC in Kano metropolis.

Usman MI et al
Findings from this study can inform policymakers on removing the identified barriers and strengthen the facilitators of using ANC services to improve maternal and child health indices in Kano and Nigeria at large.

Instrument description and method of data collection
Semi-structured adapted 10, 11 intervieweradministered questionnaire consisting of open and closed-ended questions was used for data collection. The questionnaire has five sections that elicited information on socio-demographic information, available ANC interventions for pregnant women, Knowledge of ANC intervention, facilitators of using the ANC interventions and barriers to using ANC intervention. Pre-testing of the questionnaire was conducted among 40 pregnant women attending ANC outside the selected LGAs in Kano. The questionnaires were administered by ten trained Hausa speaking research assistants with the interviews conducted in the local language.

Data management and analysis
Data were analyzed using IBM SPSS Statistics for Windows, version 20. Quantitative variables were summarized using appropriate measures of location and variability, whereas categorical variables were presented as frequencies and percentages. Questions were asked to identify the available ANC interventions provided to pregnant women during ANC services.
Knowledge domain: Thirty-nine questions were used to assess knowledge of ANC interventions based on the package of interventions provided to pregnant women during routine ANC visits namely (Long Lasting Insecticides Treated Nets, iron and folic acid supplementation, health education, sulphadoxine/pyrimethamine therapy, tetanus toxoid). Any correct response to questions assessing knowledge of ANC interventions was awarded one mark while the wrong response was given a zero point. The total score was summed up. A total score of <19 point was considered as unsatisfactory knowledge of ANC services while a score of ≥19 was considered as satisfactory knowledge of ANC services. 12 Facilitators and barriers to the use of ANC services: Questions were asked to determine the facilitators and barriers to the use of each of the identified ANC interventions used to assess the knowledge domain and were presented in frequencies and percentages. The outcome variable was knowledge of ANC interventions while the independent variable was the age, occupation, parity among others. Pearson's chi-square and Fisher's exact tests were used to test for significant association between categorical variables. Logistic regression was used to adjust for confounders and to determine Usman MI et al predictors of pregnant knowledge of ANC interventions. A p-value of 0.05 was considered significant. The criteria for inclusion of variables into the logistic regression model were apriori variables, variables found to be significant at the bivariate level, and a set of p-value of 0.2 for variables that were found not significant at a bivariate level. 8

Ethical considerations
Informed consent was obtained from eligible respondents before the questionnaire administration. The consent form was in both local language (Hausa) and English, and literate respondents indicated acceptance by signing the consent form and the non-literate ones affixed their thumbprints. Permission to conduct the study was obtained from the respective LGAs selected, heads of the selected hospitals and Health Research Ethics Committee of Kano State Ministry of Health with approval number of MOH/OFF/797/T.I/1224, approved on 24 th April, 2019 and data was collected from 10 th May, 2019 to 30 th July, 2019. All the principles of research ethics were strictly adhered to throughout the conduct of the study.

Results
Out of the 383 questionnaires distributed 374 were retrieved and analyzed, giving a response rate of 97.0%.

Socio-demographic characteristics of pregnant women attending routine ANC
The mean age of respondents was 25.7±4.8years. The majority of the pregnant women studied (60.0%) were greater than 24 years of age. Many of the pregnant women studied had formal education (96.8%). More than two-thirds of the respondents (73.0%) were employed, with gravidity of less than 5 for the index pregnancy reported among (78.9%) the pregnant women. Majority of them (94.6%) had clinic visits within the range of 1-4 times during the index pregnancy. More than three-quarter of the pregnant women (86.1%) had a monthly income of < N18, 000 with a median of N6, 000. About two-thirds of the pregnant women were urban dwellers (67.1%) as shown in table 1 below. Knowledge of ANC interventions among pregnant women The maximum knowledge score was 39 and the minimum was 10 with a mean of 24.8±5.8. Most of the pregnant women (97.0%) had satisfactory knowledge of ANC interventions as shown in figure 1 below. The majority of the respondents (90.9%) correctly answered that LLIN is used as a physical barrier to prevent mosquitoes' bites. More so, most of the pregnant women agreed that the LLIN is beneficial for the mother, fetus, infants and children. Also, about two-thirds (68.7%) of the respondents correctly mentioned the importance of iron and folic acid among pregnant women. The majority of the pregnant women (92.2%) correctly reported that health education on nutrition is an important component of ANC, about threequarters (75.7%) of the respondents correctly described the drugs used for IPT as shown in table 2.

Facilitators of using ANC interventions by pregnant women
Facilitators to the use of health education intervention were reported to be due to: Knowledge of its benefit (86.4%), having trust in healthcare workers (86.6%) and availability of interventions all the time (84.4%). Having trust in healthcare workers by the pregnant women and readily available ANC interventions were reported as facilitators to using other ANC interventions by the pregnant women as shown in table 5. Variable barriers to using various interventions were reported. The barrier to using iron and folic acid reported by about half of the respondents (50.0%) was forgetting to use the tablets, the financial capacity to transport self to the facility was reported to serve as a barrier to using LLIN by about onefourth (25.0%) of the pregnant women. In the same vain, up to one-fourth (25.0%) had fear of side effects as the barrier to using IPT as shown in table 6 below. The barrier to using some health education intervention was reported to be due to rejection by the spouse as shown in figure 2.

Discussion
This study identified that majority of the pregnant women (97.0%) attending ANC services at PHCs within metropolitan LGAs of Kano had satisfactory knowledge of ANC interventions in comparison with studies conducted in Uganda and Ethiopia that reported (98.1%) and (81.9%) pregnant women to knew the importance of LLIN in the prevention of malaria. 13,14 This suggests that healthcare education intervention provided at the ANC clinics offers significant improvements in knowledge of ANC interventions among pregnant women. Similarly, this study found out that (84.8%) of pregnant women studied were able to define IPTp unlike what was reported (23.9%) by a study conducted in Ekiti State, South-western Nigeria. 15 This may likely be due to the fact that this study was conducted within the metropolitan LGAs, with pregnant women more likely to have a formal education that can enable them to have access to a written sources of information on IPTp in addition to information during ANC visit. This, however, underscores the importance of intensifying health education programs among pregnant women at all levels on the importance of IPTp in preventing malaria in pregnancy and its associated complications. Also, about two-thirds (69.0%) of pregnant women studied were able to explain the importance of iron and folic acid in the prevention of anemia in pregnancy. This calls for sustained efforts to ensure that all pregnant women clearly understand the role of iron/folic acid supplementation especially in disabusing the cultural believes that ingestion of supplements during pregnancy can lead to the delivery of big babies thereby leading to obstructed labor and difficult deliveries. Age greater than 24 years, employment, urban residences were found to be significantly associated with a satisfactory knowledge of ANC interventions. This may be due to the tendency for older pregnant women to interact with women that had information on various interventions provided during ANC in addition to the possibility of attending ANC during the previous pregnancies there by making them have better knowledge, more so, employed pregnant women are likely to be literate and can, therefore, have access both to media and written sources of information on ANC interventions, the same applies for pregnant women residing in urban areas. Forgetfulness to use the ANC interventions was reported as one of the barriers to using ANC interventions. This may require the use of reminders and treatment support individuals possibly the spouse, which may require male involvement and participation at all levels of managing the pregnancy. In doing that, there is a need for female empowerment, improved status of women in the communities and community dialogue to achieve the involvement of husbands for reminders, having reported by about (13.0%) of pregnant women to be denied using the provided interventions at the facility by their husbands. More so, about a quarter (27.0%) of the respondents did not know the benefits of using iron/folic acid and IPTp. Therefore, there is a need for continued media campaigns by qualified healthcare workers in addition to routine health education programs on the importance of all the interventions given to pregnant women.

Conclusion and recommendations
Knowledge of ANC interventions among pregnant women was generally found to be satisfactory; however, many barriers were identified in using ANC interventions. The government should, therefore, scale up efforts to address the identified barriers to reduce the burden of maternal and infant mortality and morbidity.