Determinants of use of maternal health services in Nigeria - looking beyond individual and household factors

Background: Utilization of maternal health services is associated with improved maternal and neonatal health outcomes. Considering global and national interests in the Millennium Development Goal and Nigeria's high level of maternal mortality, understanding the factors affecting maternal health use is crucial. Studies on the use of maternal care services have largely overlooked community and other contextual factors. This study examined the determinants of maternal services utilization in Nigeria, with a focus on individual, household, community and state-level factors. Methods: Data from the 2005 National HIV/AIDS and Reproductive Health Survey - an interviewer-administered nationally representative survey - were analyzed to identify individual, household and community factors that were significantly associated with utilization of maternal care services among 2148 women who had a baby during the five years preceding the survey. In view of the nested nature of the data, we used multilevel analytic methods and assessed state-level random effects. Results: Approximately three-fifths (60.3%) of the mothers used antenatal services at least once during their most recent pregnancy, while 43.5% had skilled attendants at delivery and 41.2% received postnatal care. There are commonalities and differences in the predictors of the three indicators of maternal health service utilization. Education is the only individual-level variable that is consistently a significant predictor of service utilization, while socio-economic level is a consistent significant predictor at the household level. At the community level, urban residence and community media saturation are consistently strong predictors. In contrast, some factors are significant in predicting one or more of the indicators of use but not for all. These inconsistent predictors include some individual level variables (the woman's age at the birth of the last child, ethnicity, the notion of ideal family size, and approval of family planning), a community-level variable (prevalence of the small family norm in the community), and a state-level variable (ratio of PHC to the population). Conclusion: Factors influencing maternal health services utilization operate at various levels - individual, household, community and state. Depending on the indicator of maternal health services, the relevant determinants vary. Effective interventions to promote maternal health service utilization should target the underlying individual, household, community and policy-level factors. The interventions should reflect the relative roles of the various underlying factors.