National and subnational variations in gender relations and the utilization of maternal healthcare services in Nigeria

Introduction: poor maternal health outcomes remain a major public health issue in Nigeria. These have been shown to be affected by the low level of utilization of maternal healthcare services. This study investigates the levels of gender relations (GR) among Nigerian women and how these influence their utilization of maternal healthcare services. The relations are conceptualized as feminine (FGR), masculine (MGR) and egalitarian. Methods: data on household decision-making, antenatal care (ANC) visits, health facility delivery, and associated sociodemographic variables, were extracted from the 2018 Nigeria Demographic and Health Survey for 29,992 parous women aged 15-49 for a cross-sectional study. Associations were investigated using Chi-Square and regression analyses. Results: women with FGR constituted 5.7% of the population at the national level, while subnational variations ranged from 1.8% in the North-East to 12.8% in the South-South regions. The prevalence rates of the recommended minimum ANC visits (RMANC) and health facility delivery were 42.1% and 30.0% at the national level and were lowest in the northern regions. At both the unadjusted and adjusted levels, FGR was not significantly associated with RMANC and health facility delivery at the national level and in all the regions except the South-West. MGR was however significantly associated with increased odds of RMANC (OR: 2.235, CI: 2.043-2.444) and health facility delivery (OR: 2.571, CI: 2.369-2.791) at national level. Significant subnational variations in the association between gender relations and the utilization of maternal healthcare services were also recorded. Conclusion: sub-national variations in GR and their varying impacts on the utilization of maternal healthcare services in Nigeria suggest that gender-related policies to improve maternal health outcomes should be location-specific, rather than general. As FGR did not affect maternal healthcare services utilization, educating men on the benefits of supporting their wives to scale-up utilization is recommended.