Introduction

For over a century, the death of a woman while pregnant or during puerperium has been regarded as a public health problem [1]. This problem is more pronounced in developing countries. For instance, in 2017 the sub-Saharan African region accounted for about 66% of all maternal deaths in the world [2]. Also, the life time risk of maternal death in sub-Saharan Africa was 1 in 37 and this is very high when compared with that obtained for Australia and New Zealand which was 1 in 7800 [2]. On the country level, Nigeria bears the highest burden of maternal deaths globally [2]. There is evidence that the country also has one of the largest burdens of obstetric fistula in the world and this is a complication of pregnancy [3]. The current maternal mortality ratio for Nigeria is estimated at 512 maternal deaths per 100,000 live births and the burden is higher in rural areas when compared to urban [4].

The use of antenatal care and skilled attendant at delivery have been identified as capable of improving child survival and maternal health [2, 5, 6]. Thus, the observed differences in maternal mortality ratio between developed and developing countries could be attributed to the different rates of utilization of modern obstetric services, such as antenatal care (ANC) and skilled delivery care. In Nigeria, the utilization of maternal health services is higher in urban when compared to rural areas [4]. Suffice it to say that the use of these services is complementary as women who attended ANC four or more times have increased odds of delivering in a health facility [7, 8]. To a large extent, ensuring health facility delivery by pregnant women in Nigeria is capable of improving the high maternal death burden in the country and this should be encouraged.

Unfortunately, in most developing countries, the use of antenatal and skilled birth attendant is low and this includes Nigeria. For example, from the Nigerian Demographic and Health Survey, 57% of pregnant women in Nigeria made four or more antenatal care visits while 43% of births were attended to by skilled birth attendants [4]. It is important to note that all international efforts aimed at reducing maternal morbidity and mortality including Safe Motherhood Initiative, Millennium Development Goals and presently the Sustainable Development Goals (SDG) amongst others have all emphasized the need for good utilization of antenatal and delivery services. This brings to the fore the need to increase the utilization of these services by pregnant women in Nigeria. The SDG 3 aims to reduce global maternal mortality ratio to 70 maternal deaths per 100,000 live births by 2030. This has been interpreted as having a vision of putting an end to all preventable maternal deaths globally [2]. Consequently, there is need for Nigeria to increase its utilization of antenatal and delivery services not only to move in tandem with global trend but also to decrease the high maternal death burden which is the highest in the world at present.

A systematic review on access barriers to maternal health in low-income countries in Africa from 2015 revealed that lack of transportation to health facilities, economic factors and cultural beliefs were the main barriers to maternal health from perspective of community members and health providers [9]. The results of a study involving health providers and community key informants identified irregular and poor-quality services, inadequate human resource for health and poor governance as the health system factors militating against the use of child birth services in a rural setting in Nepal [10]. Another study in Nepal identified inadequate knowledge of services offered by skilled birth attendants, distance to health facilities and unavailability of transport services as major barriers to use of skilled birth care [11]. A study in Malawi identified delayed health care financing, inadequate human resource for health and poor record keeping as the barriers associated with maternal health care service delivery [12]. From the results of a study in Ethiopia, health providers were of the opinion that women deliver at home due to inadequate resources in health facilities and the perception by the women that delivery in health facilities is unappealing amongst other factors [13].

The providers of maternal health services have been identified as playing prominent roles in the use of maternal health services and also the satisfaction of the women with services received [14, 15]. This has necessitated the call that health workers should be trained on quality health care [14, 15]. There has been a postulation that in decreasing the high maternal mortality in Nigeria that attention should be paid to inhabitants of rural areas [14], where the burden of maternal deaths is higher [4]. It has also been emphasized that in the years beyond the Millennium Development Goals, that the key to making informed decisions towards reducing maternal mortality requires understanding of both the drivers and inhibitors of progress towards reducing the death of women during pregnancy and puerperium [16]. Furthermore, a point has been made on the need to understand factors that affect the use of maternal health services at the community level so as to be able to develop interventions that will adequately suit every community [17]. In this context, even though the utilization of skilled providers for antenatal and delivery services in southeast Nigeria is the highest among the six geo-political zones in the country, the records for Ebonyi state are the least in the zone [4]. This calls for concern and the need for improvement. This study was therefore designed to determine providers’ perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria.

Methods

Results

Discussion

All the participants were of the opinion that use of health facilities for antenatal care is higher than that for delivery services in the study area. This is similar to findings from the Nigerian Demographic and Health Survey [4], in which the proportion of women utilizing antenatal care is higher than those that deliver in health facilities. It has also been observed that the use of health facilities for delivery services is poor [14, 18]. Most of the health workers in urban and rural areas attributed the good utilization of health facilities for maternal health services to the delivery of quality healthcare in the various health facilities. This concept of quality was described by the participants in various forms. This is commendable as women have been known to avoid using health facilities for maternal health services when they are not treated with respect.

An analysis of 2012 National HIV/AIDS and Reproductive Health Survey which involved individuals that did not utilize antenatal care revealed that improvement of quality of antenatal care was rated as the most essential factor towards improving its utilization after taking care of finance and other barriers [19]. To further emphasize the importance of quality maternal health service, a study in Zambia found that the main reason for low utilization of maternal health service was perceived low quality of services [20]. It is worth commenting that one of the providers in rural area viewed the delivery of round the clock services in her facility as being equivalent to good utilization of services. In a study in Enugu state, Nigeria, it was found that providers of maternal health services perceived good utilization of services as being same as quality healthcare delivery [21]. Observations such as these necessitated calls for health workers to be trained on quality of healthcare [14, 21].

The reasons for poor utilization of health facilities for antenatal and delivery services were different among participants in urban and rural areas. In urban, participants attributed that to the poor health seeking behaviour of the women. In rural however attention was shifted to the poor attitude of health workers and the neglect of primary health centers which are the main health facilities in the area. It has been observed that efforts made to increase delivery at primary health centers is capable of decreasing the maternal mortality in rural areas of Nigeria [22]. Based on this, it has been postulated that in decreasing maternal mortality in Nigeria, attention should be given to rural areas and good utilization of primary health centers [14]. To attest to the neglect of primary health centers, a study in Enugu state, Nigeria, revealed that health centers were poorly utilized and that quality of care was also poor [23]. Such community perceptions of poor-quality care coupled with unavailable services further limit the utilization of primary health centers [24]. These feelings of poor service delivery from primary health centers could explain why most women move from rural to urban areas for antenatal and delivery services. Similarly, a study among Mesoamerican women revealed that there was a relationship between well-equipped health facilities and use of such facilities for delivery services. Thus, it was observed that women make long journeys to those facilities that were considered equipped [25]. This makes it imperative that good attention should be given to primary health centers and rural areas if the maternal death burden in Nigeria should be improved.

Most participants in urban and rural areas were of the opinion that ignorance is the main reason why women still deliver with traditional birth attendants and at home. It could be assumed that the providers were familiar with only one side of the divide. For example, in a study in northwest Nigeria, women identified ignorance, abuse and illiteracy as barriers to seeking delivery services in health facilities [26]. However, the same women attested that they patronize traditional birth attendants because their services were inexpensive and accessible [26]. This maybe an indication that there are factors that push the women away from delivering in health facilities and others that pull them to deliver with traditional birth attendants. This could account for the different reasons that make the women to patronize traditional birth attendants. For instance, in a study in southwest Nigeria, the major reasons for utilizing their services were that they were user friendly and accessible [27]. In a similar study in northwest Nigeria, women prefer delivery services from traditional birth attendants because of their positive attitude towards them and their services [28]. An influence of culture was observed in another study in northwest Nigeria, where the women preferred home delivery because of male attendants in health facilities and cost of services [29].

There are however good observations from the results of this study which point to a gradual and perhaps a possible end to the utilization of delivery services from traditional birth attendants. A participant in the urban area was certain no woman that attended antenatal care in her facility will deliver with a traditional birth attendant because of the health education the women receive during antenatal care. This remark is of good account as it has been found that women who make four or more antenatal care visits have increased odds of delivering in a health facility [7, 8]. Ensuring health facility delivery by the women is capable of improving maternal health in Nigeria. Among participants in the rural, one remarked that the involvement of a known traditional birth attendant in the ward health committee has been a boost to health facility delivery. This attests to the good report in community ownership and management of primary health centers and should be encouraged. These two approaches should be further explored towards increasing health facility delivery by the women especially in rural areas.

Elsewhere, several other reasons contribute towards encouraging women to deliver with traditional birth attendants and at home. Some of the findings are at variance with what was obtained from this study. For example, from a study in Ethiopia the main reason for utilizing the services of traditional birth attendants was because they considered health facility delivery as unnecessary and not part of their custom [30]. From the results of a study in Bangladesh, poverty was the main reason for home delivery and with traditional birth attendants [31]. However, in western Kenya, delivery with traditional birth attendants was favoured because of the flexibility of payment for their services [32]. In another study in rural Kenya, home delivery was more as a result of health facilities being too far [33]. A combination of factors including physical distance from health facility and poverty prevented women from delivering with skilled providers in Indonesia [34].

Also, most providers in urban and rural areas perceived ignorance among the women as the major barrier to the use of antenatal and delivery services in health facilities. This is similar to findings from other geo-political zones in Nigeria though from different perspectives. For instance, from a study in south-south Nigeria it was found that women were unaware of maternal health services provided in health facilities [35]. This may make them not to appreciate the capacity and capability of health workers in formal health institutions for delivery services. In northern Nigeria, the need for increasing the awareness of the people on the relevance of utilizing health facilities for maternal health services was made [36]. In another study in south-south Nigeria, the need for comprehensive health education was emphasized and the aim was to let the women know the value of utilizing skilled birth attendants for delivery purposes [37]. A study in north-central Nigeria went beyond the women and concluded that the community as a whole lacked knowledge on the benefits of delivering in a health facility and as such the need to increase community awareness on the need for such services [29]. Thus, it is of importance to enlighten the public on the relevance of health facility delivery bearing in mind the high maternal death burden in Nigeria.

It could be said that this concept of ignorance concerning use of antenatal and delivery services is not restricted to Nigeria. In an analysis of the Demographic and Health Survey of countries in sub-Saharan Africa and south Asia, it was found that after taking care of service-related barriers, there was need to enlighten the public on the gains of utilizing health facilities for maternal health services [38]. In Pakistan, the results of a study revealed that there was lack of knowledge concerning antenatal care and this was perceived as the major barrier to utilizing antenatal care in health facilities [39]. In rural Kenya, it was found that women had poor understanding of antenatal care as it was seen as just a place for the treatment of common diseases [40]. Another study in Kenya revealed that there were misconceptions about care provided by health workers hence the need for a form of re-orientation of the women through health education [41]. Similarly, in Rajasthan it was found that changing the perception of women on antenatal care and delivery in health facilities is essential in increasing demand for such services by the women [42]. This was because the women were unaware of the importance of such services.

A few of the participants in urban and rural areas ranked lack of finance as the second barrier to utilizing health facilities for antenatal and delivery services. This observation is similar to what was obtained in Kenya, where cost was the major barrier to delivering in a health facility [32]. There is however a different finding from a study in Ghana where the major barrier to use of maternal health services was inadequate medical equipment and essential medicines [43]. Suffice it to say that participants in this study did not reckon with deficiencies associated with the health system as barriers to the utilization of maternal health services in health facilities. This shows that the providers of maternal healthcare go the extra mile to cover the weaknesses of the health system and this is commendable. It has also been found that certain societal ills could affect the utilization of maternal health services. In a study in southeast Nigeria, security challenges limited the use of maternal health services in primary health centers [21]. This was because most of the health centers were not fenced and based on security concerns the health workers refrained from opening the health centers for round the clock service delivery. To an extent, the health facility being open at all times is of good record and this may have influenced the opinion of one of the participants in the rural area that her health center was well utilized for maternal health services since it was open at all times.

Most participants in urban and rural areas posited that to improve utilization, there should be a change in attitude of health workers to the women. This is contrary to their initial assertion that ignorance on the part of the women was the major barrier to the utilization of antenatal and delivery services in the study area. Perhaps the participants shied away from laying the blame on themselves. The issue of negative provider attitude among health workers is not new. From the results of a study in northern Nigeria, the main reason for non-utilization of health facilities for delivery services was negative provider attitude [36]. Elsewhere in Bayelsa state, Nigeria, it was found that health workers should encourage the utilization of maternal health services by having a positive attitude to women during visits to health facilities [35]. Aware of the need for a good provider attitude, another study in north central Nigeria concluded that antenatal care providers should be trained to improve the quality of care in the discharge of their duties [44]. This was perceived as a way of increasing utilization of health facilities for delivery services. Similarly, even though use of health facility deliveries were increasing in rural areas of Ghana, a major constraint in the use of such services was the maltreatment of the women by the health workers [45]. This was similar also to what was obtained in Kenya [32, 40].

Negative provider attitude by providers of maternal health care is at a great cost to the society. It has been ascertained that dissatisfaction with antenatal care by pregnant women could lead to preference for traditional based maternity care. Unfortunately, such actions are associated with maternal and fetal mortalities [46]. This necessitates that providers of maternal health services should provide quality maternal health service to their clients by having a good provider attitude. Realizing this feat may necessitate that health workers are trained on quality of care.

A few participants from rural area perceived that public enlightenment was very essential if the utilization of health facilities for antenatal and delivery care is to be increased. This may support the opinion of providers that ignorance is the most limiting factor to the use of health facilities for antenatal and delivery services. This finding is similar to what was obtained in Sokoto, Nigeria where the use of health promotion interventions was advocated so as to improve health facility delivery by women in rural area [47]. There has also been a call for community education aimed at increasing skilled attendant at delivery in rural Nigeria [48]. Even in studies outside Nigeria, there has been overwhelming calls to increase community awareness on the importance of utilizing health facilities for antenatal and delivery services [32, 49]. From a study in Nepal, it was observed that women had poor knowledge of services offered by skilled birth attendants [11]. In Indonesia, there was emphasis in maximizing health promotion efforts in increasing community awareness of using health services generally [34]. This was because use of health facilities for sundry services in that region was poor. Bearing in mind the high maternal death burden in Nigeria, there is need to increase community awareness on the utilization of health facilities for maternal health services. This will cater for the ignorance of the women on the use of such services. This should be complemented by training health workers on quality of care so that the continual use of health facilities for such services by the women could be guaranteed.

All the participants in urban and rural areas were in favour of the involvement of men in matters related to maternal health services. This was based on the useful role men could play in the affairs of the family. Thus, involvement of men has been viewed as a strong influence in the health of their partners and children [50]. Perhaps, because delivery is a one-time facility visit, it was observed that more men accompany their wives for delivery services than antenatal care. Suffice it to say that the need to involve men in issues related to maternal healthcare is of relevance. For example, a study in rural Nigeria concluded that community elders should be supported to initiate rules that will promote the involvement of men in maternal health as this has the capacity of increasing the use of skilled attendants by women during delivery [51]. Similarly, another study in northern Nigeria advocated the involvement of men in matters related to delivery of maternal health services [52].

Similar observations have also been recorded in studies outside Nigeria. For instance, there has been a call to address the barriers in involving men in maternal health issues in Ghana [53]. Also, in Zambia, it was advocated that health education programmes should encourage male involvement in the decision of pregnant women to seek antenatal care so as to encourage adequate use of services [54]. These observations may indicate the need to involve men in use of health facilities for maternal health services as this may have a good role to play in reducing the maternal death burden in Nigeria.

Conclusions

Participants were aware of values of good provider attitude and this is commendable. This combined with the finding of poor attitude of health workers necessitates that health workers are trained on quality of care. There is need for public enlightenment on importance of utilizing health facilities for antenatal and delivery services. Community ownership of primary health centers especially in rural communities will enhance utilization of such facilities and should be strengthened. Efforts should be made to involve men in matters related to maternal healthcare as this may have a positive influence in improving maternal health in Nigeria.

Supporting information