Determinants of Maternal Health- Seeking Behaviour in Nigeria: a multilevel approach

Maternal health remains a major challenge in developing countries despite improvements in medical technology and several efforts to improve maternal health care services. The high maternal mortality ratio of 630 per 100, OOO live births in Nigeria suggests that the maternal health situation in the country is very poor. Attempts to explain this situation have focused on  individual and household level determinants, but the role of community factors has not received much attention. Understanding community factors associated with maternal healthseeking behaviour is important. This is because individuals reside within communities and their health related behaviour can be influenced by the characteristics or conditions of the community in which they live. The purpose of this study is to understand how maternal health-seeking behaviour in Nigeria is influenced by a combination of individual, household and community conditions. Specifically, the objectives of the study are: (1) to examine the patterns of and differences in maternal health-seeking behaviour in Nigeria, (2) to examine the impact of community factors on maternal health-seeking behaviour, and (3) to investigate whether community factors moderate the association between individual/household factors and maternal health-seeking behaviour.

The study analyzes data from the 2008 Nigeria Demographic and Health Survey. The study population included women aged 15-49 years who had given birth to their last child in the five years preceding the survey. Four categories of maternal health-seeking behaviour indicators were used in the study, which include antenatal care visits, skilled antenatal care, place of delivery and skilled postnatal care. The sample size consisted of 16005 women for antenatal care visits, 17560 for skilled antenatal care, 17542 for place of delivery and 17437 women for postnatal care. The study employed bivariate statistics, and multilevel logistic
regression models. Bivariate analysis was utilized to examine the patterns of and differences in maternal health-seeking behaviour (antenatal care visits, skilled antenatal care, place of delivery and skilled postnatal care). Multilevel logistic regression was used to examine the independent effects of community characteristics on maternal health-seeking outcomes/behaviour; and the moderating effects of community factors on the association between individual/household factors and maternal health-seeking behaviour. Results showed that the level of maternal health-seeking behaviour among women in the sample population is low. For example, fewer than half ( 46.1 % ) of the women had had four or more antenatal care visits, 54% had received skilled antenatal care, about 34.4% had had a health facility delivery, and only 30.1 % received skilled postnatal care. The study also found that there were differentials in maternal health-seeking behaviour with respect to the individual and
household and community characteristics of the women. In line with expectations, results showed a higher likelihood of seeking maternal health care among women with higher education and those from the richest households. Results also indicated that women from large households and those of higher parity (5 and above) were less likely to seek maternal health care than women from small households and those oflower parity (1-2) respectively.

Furthermore, women from Igbo, Yoruba and Northern/Southern minority ethnic groups were found to have higher odds of attending four or more antenatal care visits, receiving skilled antenatal care, having a health facility delivery and receiving skilled postnatal care than Hausa women. A higher likelihood of seeking maternal health care was observed among women who were in formal employment. Women who reported that money, transport and distance to health facility were problems in accessing health care were less likely to make four or more antenatal care visits, receive skilled antenatal and postnatal care and deliver in a health facility. TI1e study found that women who resided in Northern regions had a lower likelihood of receiving maternal health care. This could be linked to strict cultural and Islamic religious practices being predominant in northern Nigeria. Generally, the results indicated that women from the western region of Nigeria had a higher likelihood of seeking maternal health care; this could be related to a higher level of education among women in this region, hence greater awareness of maternal health care services and the need to seek care.
The study indicated an appreciable, significant variation in maternal health-seeking behaviour across communities. This significant variation was attributed to both the characteristics of the individuals residing within communities and the characteristics of the communities of residence. The study found that community factors were significantly associated with maternal health-seeking behaviour. Specifically, women from communities with a high proportion of educated women, high proportion of those that delivered in a health facility, and high proportion of women exposed to mass media were more likely to seek maternal health care than those from disadvantaged communities. Residing in communities with a high level of poverty was associated with lower odds of seeking maternal health care.
An interesting finding of the study is that women living in communities with a high proportion of women from different ethnic groups had significantly lower odds of having a health facility delivery, suggesting the possible effect of heterogeneity and the associated formal relationships which do not encourage shared health practices. More importantly, the findings of the study indicated that community factors acted as moderators on the association between individual/household factors and maternal health-seeking behaviour. After controlling for individual/household and community variables, the significance of some of
the individual/household factors disappeared (for example, maternal age at last birth).

The significant variations in maternal health-seeking behaviour indicate that factors other than those included in the analysis are causing the clustering or variations in the outcome variables observed across communities. The result suggests the need for future studies to investigate other factors that may account for the unexplained community variations in maternal health-seeking behaviour. The regional differences in maternal health-seeking behaviour can be changed through region specific policy and reforms that ensure equitable distribution of need-based resources. The findings of the study also underscore the need to implement maternal health care service interventions not only at the individual level, but also at the community level. Such interventions should take into consi1~ration the characteristics of the community in which women reside. Furthermore, interventions aimed at encouraging maternal health-seeking behaviour in Nigeria should focus on poverty reduction programmes, increasing women's education and health facility delivery in disadvantaged communities. The community variations in maternal health-seeking behaviour are modifiable and can be altered through coherent policy at the community level.