Barriers to Use of Healthcare During Pregnancy in Nigeria

INTRODUCTION: In sub-Saharan Africa, access to care during pregnancy and child birth is an abiding challenge for many women. Many women face socioeconomic, cultural, and physical barriers while attempting to access healthcare facilities during pregnancy. These barriers often result in women accessing healthcare facilities after life-threatening complications develop, ultimately leading to high rates of maternal mortality. In Nigeria, several locally endemic diseases, such as malaria and HIV, impinge on population health. Having access to care during pregnancy provides an opportunity for prompt diagnosis, treatment, and prevention of common endemic disease. This dissertation focused on access to care during pregnancy in Nigeria by using two indicators: malaria parasitemia and Cesarean-section (CS). Therefore, this dissertation had two overarching goals. The first was to estimate the prevalence of malaria parasitemia during pregnancy and to determine maternal risk factors associated with high malaria parasitemia in Enugu State, Nigeria. The second was to establish the incidence of CS and to determine the socioeconomic and medical risk factors that are associated with having a CS among women in Enugu State, as well as in Nigeria as a whole. METHODS: Secondary analyses of two unique datasets––Healthy Beginnings Initiative (HBI) and the Nigerian Demographic and Health Survey (DHS)––were conducted. The HBI cohort study took place in Enugu State, Nigeria. The prevalence of peripheral malaria parasitemia in Enugu State was established within the context of HBI. Malaria parasitemia was scored according to the Malaria Plus System (0 to ++++). For this dissertation those in the 0 and + group were classified as low having parasitemia; while those in the ++ and +++ groups were classified as having high parasitemia. Person-level maternal risk factors that were associated with high malaria parasitemia were estimated using crude and adjusted logistic regression modeling with malaria parasitemia as the main outcome. The incidence of CS in Enugu State was also estimated within context of the HBI cohort. Socioeconomic and medical risk factors associated with having a CS in Enugu State, Nigeria were estimated. To investigate the extent to which the findings from the HBI represent the rates of CS in Nigeria as a whole, the Nigerian DHS was utilized. The Nigerian DHS was a cross-sectional study that was conducted throughout Nigeria. The incidence of CS in all of Nigeria was estimated. Socioeconomic and medical risk factors associated with having a CS were also investigated. Crude and adjusted logistic regression models with CS as the main outcome are presented. Weights were applied to all analyses conducted with the DHS to make the data representative at the county level. RESULTS: Over 99% of women in the HBI study tested positive for peripheral malaria parasitemia. For each additional person in the household, a 6% lower odds of high malaria parasitemia was found (p<0.05). Regarding CS, analyses of both datasets indicated that Nigeria has relatively low rates of CS compared to the World Health Organization's recommendations. In the HBI, 7.2% of women in Enugu State, Nigeria had a CS. Significantly lower odds of having a CS were observed among women who live in a rural setting compared to those who reside in an urban setting (p<0.05). Percentages of CS increased significantly as maternal age and/or education increased. HBI results demonstrated 53% higher odds of having a CS if participants had high malaria parasitemia compared to those with lower malaria parasitemia (p<0.05). Results of the DHS yielded even lower rates of CS with only 2.3% of women in Nigeria overall having had a CS during their last delivery. Consistent with analysis for Enugu State, in the DHS women living in rural areas had significantly lower odds of having a CS than those living in urban areas (p<0.05). Likewise, religion was significantly associated with having had a CS; Muslim women had 54% lower odds of having a CS compared to Catholics (p<0.05). Women who had health insurance and women who received prenatal care from a skilled birth attendant had increased odds of having a CS compared to women who did not have insurance and received no prenatal care (adjusted OR [aOR] 1.78: 95%CI 1.18-2.67, p<0.05; aOR 3.00: 1.51-5.96, p