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Ene and Ajibo BMC Public Health (2023) 23:2070
https://doi.org/10.1186/s12889-023-16929-5 BMC Public Health
*Correspondence:
Jacinta Chibuzor Ene
jacinta.ene@unn.edu.ng
1Department of Social Work, University of Nigeria, Nsukka,
Enugu State 410001, Nigeria
Abstract
Introduction Quality care delivery is an essential lifesaving interventions for maternal healthcare and reduction
in mortality from preventable reproductive conditions. In African countries like Nigeria, numerous perceptions and
militating factors present unique challenges in optimizing the utilization of maternal and reproductive healthcare
services. As women continuously evolve away from the utilization of healthcare services, achieving universal health
coverage for all emerges as a matter of concern.
Method A phenomenological and descriptive research design was used. The study participants comprised a total
of 38 women selected from primary and tertiary healthcare institutions. They were purposively selected from four
healthcare institutions in Nsukka, Enugu State, Nigeria.
Result Findings revealed that most rural women at the prenatal stage, utilize maternal healthcare services, but at
the postnatal stage, they reject reproductive healthcare services owing to certain perceptions. Concerns about sub-
optimal utilization of maternal and reproductive healthcare services were found under enabling, predisposing and
need factors. Evidence-based interventions included instituting health insurance policies, improving the healthcare
sector, personnel, collaboration among stakeholders, and grass-roots community education. Participants showed little
knowledge of social workers’ engagement in healthcare institutions.
Conclusion Functional network of care between private and public healthcare system is the key to optimizing
maternal and reproductive healthcare utilization. The study recommends stakeholder and community engagement
in achieving functional networks of care, strengthening relational linkages between frontline health workers and
equip rural women with better knowledge. All these are geared toward achieving optimal utilization of maternal and
reproductive healthcare services among women in low-resourced Nigerian settings.
Keywords Healthcare, Maternal, Optimizing, Utilization, Reproductive, Women
Optimizing the utilization of maternal
and reproductive healthcare services among
women in low-resourced Nigerian settings
Jacinta Chibuzor Ene1* and Henry Tochukwu Ajibo1
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Ene and Ajibo BMC Public Health (2023) 23:2070
Introduction
Across the globe, the contributions of women to the wel-
fare of families, communities and nations are of utmost
importance. As such, their health welfare during and
after childbirth should be given great priority. is stems
from the fact that a mother’s death has profound conse-
quences on her family. en, optimizing maternal and
reproductive healthcare services utilization remains a
mandatory step in accomplishing the Sustainable Devel-
opment Goal (SDG):3 “to ensure healthy lives and pro-
mote well-being for all’ [34].
Globally, quality healthcare delivery is an essential
lifesaving intervention. In most sub-Saharan African
countries particularly Nigeria, the high burden of mater-
nal and child mortality persists [26]. e country with
2.4% of the world’s population, contributes to 10% of
global deaths for pregnant mothers [38]. Nigeria, fur-
ther accounts for the fourth-highest maternal mortality
rate of 576 per 100,000; with the second-highest child-
birth death rate of approximately 262,000 babies [41]. It
is important to note that above half of the maternal and
neonatal deaths occur from attempted abortion, and
pregnancy-related complications, particularly maternal
hypertensive disorders, pre-eclampsia, hemorrhages, the
premature rupture of membranes and infections [40]. As
women age, they are vulnerable to illnesses including pel-
vic damage, cervical and breast cancer, fibroid, and other
urogenital infections. Given the current challenges, it is
envisaged that we will fall short of what is needed to real-
ize the Universal Health Coverage (UHC) and SDG:3 tar-
get. is is a source of concern in the healthcare sector.
Maternal and reproductive healthcare services are del-
egated with providing adequate maternal and perinatal
health, well-being and ending preventable feminine mor-
tality [31]. It also encompasses monitoring of person-cen-
tered quality and respectful maternal and perinatal care,
providing guidance, routine check-ups and recommend-
ing functional networks of care to optimize linkages for
efficient and resilient healthcare systems [40]. Sadly, the
feasibility of implementing a network of care to improve
maternal and reproductive outcomes is sub-optimal [26].
e reason is that the quality of maternal care is a pro-
found factor that impacts the delivery of a continuum of
care among women in most of the sub-Saharan African
countries. is situation subsequently increases women’s
use of alternative healthcare services. For instance, it has
been reported that 66% of livebirth categorized as non-
institutional health delivery occurs in the presence of a
mid-wife, relative or self-assisted birth [14]. Available
evidence shows that in Nigeria, there is a deficiency in
hygiene, contraceptive usage, and safe medication cul-
ture; which compromises patients’ safety [12, 19, 29].
Further, [28], posit that healthcare financing is the worst
hit in the country, constituting 72% and 95% of public
and private health expenditure in 2018 respectively.
Studies have shown that women’s ability to adopt rou-
tine check-ups and access appropriate treatment and
services in health institutions is anchored on the vari-
ous perceptions and factors of maternal and reproduc-
tive healthcare services utilization [27, 35, 42]. First is
the perception of ante-natal and post-natal care services,
delay in service delivery, fear of adverse health outcomes,
cultural and religious assumptions [4, 11]. Again, factors
including inequality in the distribution of health facilities
between urban and rural areas, dilapidating equipment,
inadequate number/attitude of health personnel, increas-
ing corruption levels in the health sector, diseases, infec-
tions and high levels of household out-of-pocket payment
for health goods and services, have been found in studies
[15, 37]. Worrisome are concerns ranging from ignorance
of women owing to their socio-demographic character-
istics including age and educational status, occupation,
influence of spouse decision; associated with low health-
care utilization and unhealthy living has been reported in
the literature [14, 15].
Although in recent years, global investment in the
health sector has been high. Nevertheless, the situation
in the Nigerian healthcare system stems from reduced
investment in the public health sector, high demand for
healthcare services; a backlog of procedures, increas-
ing cost of drugs, equipment and services [29]. Like
other African countries, Nigeria operates a three-level
healthcare sector including primary healthcare facili-
ties, secondary health institutions (general hospitals)
and a tertiary healthcare system (teaching hospital).
ese health institutions allocation is skewed; with a
higher proportion going towards secondary and ter-
tiary health institutions while the primary health facili-
ties are neglected [24]. is is evident from the fact that
negligence of the primary healthcare facilities results in
women’s low utilization of maternal and health services
particularly in the rural settings where it is predominant
[21]. is falls short of the standard set by the World
Health Organization’s initiative on safe motherhood.
Against these backdrops, it is needful to provide effec-
tive, quality, accessible and affordable healthcare ser-
vices, particularly for rural women. is can be achieved
through the engagement of stakeholders, communities
and health workers in both the government and private
sectors [26]. It is envisaged that efforts aimed at address-
ing this problem will lack some form of efficacy without
the inclusion of medical social workers. is is incum-
bent on the roles social workers play in families, com-
munities and collaboration with health practitioners.
Specific to this context, social workers are expected to
lobby, advocate, and intensify education on healthcare
utilization [3]. ey could push for a new narrative on
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Ene and Ajibo BMC Public Health (2023) 23:2070
early healthcare visitation, organize counseling and dis-
course sessions for support networks of patients, draw
follow-up programs, enlighten and encourage them
on compliance with health laws [25]. ese efforts it is
believed, will ensure an improved care system, optimal
utilization of healthcare services and attaining a low pro-
portion of maternal and neonatal child mortality. is is
the gap this study hopes to fill.
In this study, therefore, an attempt is made to deter-
mine measures that will foster optimal utilization of
maternal and reproductive healthcare services among
women in low-resourced Nigerian settings. e study
becomes important in Nsukka Local Government Area
(L.G.A), against the background that there is a bias
about rural areas in the implementation and monitoring
of institutional healthcare facilities [13]. It is given the
bias implicated in poor healthcare delivery, particularly
in rural communities; that the study is anchored on the
health service utilization model. Anderson and New-
man’s [2] model of health service utilization serves as
the theoretical underpinning of this paper. According to
the model, the perception of maternal and reproductive
healthcare service utilization by women is categorized
under a series of factors including predisposing, enabling
and need factor. e predisposing factors are socio-
demographic characteristics including age, marital sta-
tus, and parity (number of children), while the enabling
factors include educational attainment, occupation
and income [27]. In this study, however, the need fac-
tors adopted were the past experiences of rural women,
service provider’s attitude and competencies, the cost
of delivery, accessibility and environment of the institu-
tional health facility. It then follows that the purpose of
this study was to examine how these factors influence the
perception and determine the utilization of maternal and
reproductive healthcare services.
To date, numerous studies abound that have discussed
optimizing maternal and reproductive healthcare ser-
vices, particularly in sub-Saharan African countries,
Nigeria inclusive [4, 15, 27, 42]. Of all these studies,
none falls under the purview of medical social workers,
particularly at the grass-roots level. is study, there-
fore, contributes to the existing literature on maternal
and neonatal health, advocates for quality improvement
in maternal and reproductive healthcare services, and
ensures the integration of medical social workers in
the rural community healthcare sector. It is against this
background that this study poses the following research
questions: (a) what perception holds on the utilization
of maternal and reproductive healthcare services among
women in low-resourced societies? (b) what factors influ-
ence the utilization of maternal and reproductive health-
care services among women in low-resourced societies?
(c) what interventions can intensify the utilization of
maternal and reproductive healthcare services among
women in low-resourced societies? (d) what is the
involvement of social workers in ensuring the utiliza-
tion of maternal and reproductive healthcare services in
Nigeria?
Theoretical framework for optimizing maternal and
reproductive healthcare services utilization
We anchor our theoretical framework on the model
of health service utilization propounded by Anderson
and Newman [2]. e model has been adopted by [5] to
examine the use of health services by adolescent girls in
South-East Nigeria. Further, [33] employed this model
in investigating older adults’ behavior in receiving long-
term services and support. e choice of this model is
to understand and explain how and why people use cer-
tain types of health services. e model argues that the
use of maternal and reproductive healthcare services by
rural women is a function of their predispositions. is
is categorized under need, enabling and predisposing fac-
tors. e key to the adoption of this model is to explore
the determinants of women’s utilization of healthcare
services, improve the quality of healthcare services and
facilitate the policy-making process for equitable care
and health services review.
In this study, we discovered that the predisposing fac-
tors (age and marital status) have a minor impact on
health service utilization while the enabling (educational
attainment, occupation and income) and the need factors
(proximity of healthcare facilities, accessibility of health
institutions, competencies and poor quality of care by
health workers) are dominant predictors of maternal and
reproductive healthcare utilization among rural women
in Nsukka L.G.A. Further, women in this study aside vari-
ous predispositions, expressed perceptions on cultural,
religious and mystic assumptions as other determinants
of maternal and reproductive healthcare utilization. It is
against these backdrops, that we suggest the interven-
tions of medical social workers in rural communities. We
envisage that these professionals can help ensure optimal
maternal and reproductive healthcare utilization among
rural women by advocating for a functional network of
care between the private and public care systems, adopt-
ing grass-root community health education, collabora-
tion with health personnel, and indulging in home-health
visits, among other measures. ese suggestions, it is
hoped, will optimize health services utilization, improve
quality care program and reduce maternal and neonatal
mortality in Nsukka, Enugu State, Nigeria.
Methods
Study design
In this current study, descriptive and phenomenologi-
cal research designs with a qualitative research approach
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Ene and Ajibo BMC Public Health (2023) 23:2070
were employed in generating data. e descriptive
research design aims to obtain in-depth information to
systematically describe a phenomenon, situation or pop-
ulation [39]. Phenomenological approach is concerned
with the perspectives and interpretations of people based
on their experiences as it seeks to gain further insight
into the thinking and behavior of women [10]. Employ-
ing these research designs, the researchers were able to
describe in detail the narratives of women from low-
resourced Nigerian settings on perceptions, challenging
factors and measures to ensure optimal utilization of
maternal and reproductive healthcare services.
Study participants and recruitment
e study involved a purposive selection of three primary
and one tertiary healthcare institution. e names of the
health institutions are withheld for confidentiality and as
requested by the health administrators. e study par-
ticipants comprised a total of 38 women selected from
four primary and tertiary healthcare institutions. e
first category of participants were 27 expectant women
in the Out-Patient Care (OPD) unit involved in three
Focus Group Discussions. e second category consisted
of nine women who have delivered and are awaiting dis-
charge in the In-Patient Care (IPC) unit. Whereas, two
medical social workers in a tertiary healthcare setting
served as the third category of participants. e second
and third categories of participants were involved in
eleven in-depth interviews. It is important to note that
equal participants were drawn from the three primary
health institutions. Since there are no medical social
workers in any of the primary healthcare institutions, the
two social workers were drawn from one tertiary health
institution.
Study area
e participants for this study were drawn from Nsukka
Local Government Area (LGA). Nsukka is situated in
Enugu-North senatorial district within the southeast geo-
political zone in Nigeria. e rationale for selecting the
study area was because it operates a three level healthcare
sector including the primary healthcare facility (Nsukka
Primary Healthcare Center), secondary health institution
(Nsukka General Hospital) and the tertiary system (Uni-
versity of Nigeria Medical Center) [16]gain, the locality
is a semi-urban settlement with a major urban town, and
17 rural communities [36]. Hence, most rural indigenes
owing to proximity, migrate to the town for healthcare
services. In addition, studies have shown that the locality
is one of the disease holo-endemic Nigerian communities
with great economic burden on healthcare financing [22,
35]. e estimated population of Nsukka is 309,448 com-
prising 149,418 males and 160,030 females [8]. e local-
ity has small-sized private (for-profit) health facilities but
is dominated by government and mission health institu-
tions [16, 23].
Sampling procedure
For this study, the non-probability sampling method was
employed. In this regard, purposive and availability sam-
pling were deployed for selecting the study participants.
e justification was that a unique target population was
needed for the study. e target population comprised
expectant women of up to six months, who are registered
in the ante-natal care (OPC) service of the selected pri-
mary health facility. Also, women in post-natal care (IPC)
who delivered at the time of this study and two medical
social workers were selected. e study employed avail-
ability sampling to ensure that only available and willing
participants were recruited in the study.
Data collection
Data was collected using three focus group discussions
and eleven in-depth interviews. Although in-depth inter-
views served as the main source of data collection, we
were particularly interested in the rich data that is often
generated in focus groups owing to the large number of
ideas, issues and even solutions to a problem, as cited in
qualitative studies [7, 9]. As social workers and research-
ers, we were also concerned with exploring and under-
standing the common and divergent experiences of rural
women in the utilization of maternal and reproductive
healthcare service in Nsukka, Nigeria, where medical
social workers are not yet recognized. By understanding
the common concerns and differing opinions, policies
and programmatic actions can be initiated. Furthermore,
the qualitative research method avail participants the
opportunity to express their personal lived experiences
with other women, while also providing them with the
opportunity to learn from the tales of other women and
reflect on the utilization of maternal and reproductive
healthcare services. Informed consents to participate in
the study were verbally obtained from the study partici-
pants after they were enlightened on the objectives of the
study. e participants were assured of the confidential-
ity of every information or data they provided. ey were
also informed that they were at liberty to decline partici-
pation in the study at any stage of the interview if they
no longer felt comfortable. is enabled the study partici-
pants to feel free and give out information without fear or
prejudice. is informed the credibility and objectivity of
the data obtained from the participants and the analysis
process.
e researchers with two research assistances collec-
tively developed the Focus Group Discussion (FGD) and
In-Depth Interview (IDI) guides. ey were made up of
semi-structured questions and probes. According to [20],
probes help in a deeper understanding of context through
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Ene and Ajibo BMC Public Health (2023) 23:2070
narratives that described the tales of women rather than
a rudimentary guide. ree focus group discussions were
held in the three primary health institutions. e data
collection phase for the FGD started with some introduc-
tory activities. is allowed for the two research assis-
tants who served as the note-taker and recorder to meet
with the research participants informally so that they
become more comfortable during the data collection
process. Interviews and discussions took place between
5th February and 26th March 2023. ree Focus discus-
sions and nine interviews were held in Igbo and English
based on the convenience of the participants. ese lan-
guages are familiar to the researchers, hence there was no
need for an interpreter. In all, none of the interviews and
discussions lasted more than 90min to prevent fatigue.
In this study, we were guided by the phenomenologi-
cal qualitative research approach which allowed us to
discuss our participants’ experiences and concerns
regarding our research topic [17]. is approach attaches
importance to rich contextualized descriptions based on
experiences and is free from pre-existing prejudices [32].
Again, it enabled us to adequately capture the partici-
pants’ phrases and nuances, see events as they appeared
to them and as well minimize the impact of the research-
ers when collecting and analyzing data.
Data analysis
e data analysis technique began with note-taking and
careful audio-recording of all the discussions and inter-
views. Data were analyzed after transcribing the discus-
sions and interviews in English language. is was to
enable easy understanding. e researchers who did the
transcriptions are grounded in Igbo language, though
only a few participants expressed themselves in Igbo lan-
guage. After translation and transcription, data immer-
sion commenced by repeatedly hearing the audio and
reading the transcribed discussion and field notes for
familiarization. e data analysis process followed the
qualitative procedure of data reduction, data display and
conclusion. We compared the contents of the transcripts
with the field notes and recorded information to ensure
coherence.
Next, we coded the data in parent and child nodes. e
coded data were further checked, grouped and catego-
rized by other researchers. An inductive coding approach
was adopted, meaning and themes were generated as
we studied the transcript. is was done to ensure that
codes with similar characteristics were grouped themati-
cally to arrive at key themes. e use of thematic clus-
ters to understand and communicate qualitative data
is rooted in phenomenology [9]. ematic analysis was
employed to enable the researchers to categories the data
into themes for easy comprehension. To increase the
rigor of our analysis, two peers who did not participate
in the study reviewed the dataset in keeping with peer
debriefing and observer triangulation [30]. eir insights
contributed to the final checks on the analysis. ese
exercises are in line with [10] overview of the qualitative
research method. In this study, the final themes include:
• Perception of the utilization of maternal and
reproductive healthcare services among women in
low-resourced societies.
• Factors that inuence the utilization of maternal and
reproductive healthcare services among women in
low-resourced societies.
• Interventions that can intensify optimal utilization
of maternal and reproductive healthcare services
among women in low-resourced societies.
• Assessment of the involvement of social workers
in ensuring optimal utilization of maternal and
reproductive healthcare services among women in
low-resourced societies.
Finally, special connotations that addressed the research
questions were pulled out as illustrative quotes from the
thematic cluster to exemplify the key issues. Inscriptions
were used to connote the study group (FDG- Focus Dis-
cussion Groups and IDI- In-depth Interviews).
Ethical consideration
Ethical clearance for the study was sought from the insti-
tutional review board of the Strategic Contacts Ethics
Publications (STRACEP) of the University of Nigeria,
Nsukka campus, Enugu State; before the discussions and
interviews commenced. All methods of data collected
were carried out in accordance with relevant institu-
tional guidelines and regulations. e need for written
informed consent was waived by the institutional review
board (IRB) of the Strategic Contacts Ethics Publications
(STRACEP) of the University of Nigeria, Nsukka campus,
Enugu State. e justification for the waived informed
consent was because it was deemed unnecessary as the
rural women volunteered to participate in the study. e
participants were informed of their freedom to withdraw
at any time in the course of the study. In all, they were
assured of anonymity and confidentiality.
Result
e results of our findings are presented in themes and
subthemes. First, the researcher started by presenting the
socio-demographic features of the study participants.
Demographic characteristics of participants
In this study, there are 38 participants aged 30–59 years.
A majority (80%) of the participants were younger
women aged 30–44 years. ey are predominantly
Christians by religious affiliation and are married with
children. Most (56%) attained and completed primary
education, some (38%) attained but did not complete
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Ene and Ajibo BMC Public Health (2023) 23:2070
secondary and post-secondary school education, whereas
few (16%) completed tertiary education. All the study
participants are of the Igbo ethnic group. A good num-
ber were businesswomen and housewives while a few
were civil servants. Most of the participants (67%) earned
above 50,000 naira ($30) while others earned below.
Perception of the utilization of maternal and reproductive
healthcare services among women in low-resourced societies
Concerning this view, the participants highlighted three
key issues. First, some of them responded that the low
utilization of maternal and reproductive healthcare ser-
vices was due to cultural norms. Others were of the view
that it remains a personal decision prompted by one’s
religious belief and the preference for local birthplace
owing to past experiences. A few participants stressed
on the mystic assumptions associated with fear of knowl-
edge of adverse health outcomes. Listed below are some
typical quotes:
Traditionally, childbearing is used to assess a wom-
an’s strength and actual age. Under normal circum-
stances, women wish to adopt normal childbear-
ing methods. Oftentimes, complications may occur
and there may be a need for alternative (cesarean
operation) childbearing methods. Expectant women
may decline from the utilization of maternal health
facilities so that they can have normal childbearing
[FGD, Trader, 36 years].
Actually, my religion is against the use of reproduc-
tive healthcare services. For instance, the insertion
of birth control items is against my faith. But, in
the facilities, it is recommended to enable the spac-
ing of children. I only use the natural method [IDI,
Housewife, 43 years].
Aside, the ante-natal and post-natal healthcare, I
do not need maternal healthcare services. e rea-
son is that I can only attend medical examinations
when I am sick. But when you visit maternal health
institutions for medical examination; certainly you
may be informed of one sickness that has emerged
and this is very scary [IDI, Trader, 31 years].
Years back, when I went for a medical examination,
I was informed of having kidney stone. I rejected this
information. It was later found that I had kidney
inammation, which required the consumption of
water. e false medical information almost aected
my wellbeing [FGD, Civil servant, 42 years].
Often, people have the perception that unknown
sickness does not kill, but what kills is known ill-
health. is is because you are only afraid of what
you know and so it is better that you do not know
of any ill-health you have till it evolves. After all, we
must die someday [FGD, Civil servant, 39 years].
Indeed, I attend ante-natal and post-natal child
care services before and after birth delivery. But I
do not give birth in healthcare facilities because I
choose to give birth in local birth homes. e mid-
wives talk gently and will encourage you through the
painful delivery period. is help to reduce the pains
in childbearing [IDI, Housewife, 30 years].
us, from the discussions, we found that women’s per-
ception of the utilization of maternal and reproductive
healthcare services is influenced by cultural norms, reli-
gious beliefs, past experiences and mystic assumptions.
Based on these impediments, they belief that utilization
of reproductive healthcare services anchors on fear of
adverse health outcomes. Few participants, however, felt
that utilization of maternal and reproductive health ser-
vices was a determinant of choice and not a necessity.
Factors that inuence the utilization of maternal and
reproductive healthcare services among women in low-
resourced societies
In this theme, we present the factors that influence the
utilization of maternal and reproductive healthcare ser-
vices among women. Contrasting views were raised by
the participants in this regard. While some participants
noted the enabling factors including women’s educational
status, occupation and economic level, others reported
need factors like proximity of healthcare facilities, acces-
sibility of health institutions, and poor quality of care by
health workers. Few participants stressed on predispos-
ing factors like age and marital status of women.
Enabling factors
ough some participants deemed it necessary for
women to utilize healthcare facilities during and after
maternal care, others had disregard due to factors such
as women’s educational status, occupation and economic
level. ey emphasized that women are most affected by
these factors owing to gender marginalization which pre-
vails in the study locality. Hear these quotes:
Women are stereotyped in our society because we
are in a patrilineal environment. Our education is
assumed to be irrelevant, so they are denied equal
educational opportunity with the males. Our low
educational status aects our occupation and level
of income. is discourages healthcare utilization
because educated women are very much aware of
the importance of routine reproductive health check-
ups and maternal care in health facilities [FGD,
Civil servant, 47 years].
e cost of service charges in health facilities is
expensive. For instance, I have observed that the
use of non-institutional health facilities is because
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Ene and Ajibo BMC Public Health (2023) 23:2070
of service charges. In most cases, the cost of service
charged often results in premature discharge. is
also patterns to other healthcare services where you
pay for routine check-ups, contraceptives and other
services [IDI, Civil servant, 34 years].
Need factors
ere was a consensus on the need factors that influence
the utilization of maternal and reproductive healthcare
services among women in low-resourced societies. e
factors highlighted by the participants include proximity
of healthcare facilities, accessibility of health institutions,
competencies and poor quality of care by health workers.
Below are the responses from the participants:
Our government is ignorant of what is happening
to us. e hospitals are far from us and the health
centers are not well equipped. We just have to use
what we have to help ourselves. We cannot die going
to those far places or go to the health center in our
community where you will not see anybody at night
when you want to give birth. Why will I go to a gov-
ernment hospital when there is a good birth center
in our community that is doing the same thing and
even better than all these private and government
hospitals [FGD, Businesswoman, 40 years].
In my last pregnancy which began at midnight, my
husband took me to the hospital where I registered.
I was in the waiting room for over 20min before one
of the health workers reluctantly went to pick up my
folder from the shelf. e other healthcare provider
was in deep sleep. By the time the other who went to
get my folder came back, I have already delivered my
baby in the waiting room [FGD, Trader, 32 years].
While this participant was still sharing her personal
experience, another participant quickly added:
When you are in labor pains, some healthcare pro-
viders use abusive language. Some also inform
the woman in labor not to disturb them with her
screams as they were never consulted during her sex-
ual relationship [FGD, Housewife, 28 years].
Many of the study participants though acknowledged
the fact that healthcare assistance is very stressful, they
were however of the opinion that healthcare provision
especially with expectant mothers should be carried out
with tenderness and care. Most of the study participants
identified challenges such as absenteeism, negligence,
long waiting time, health provider competencies, and
unfriendly attitude among others; as the reasons that
discourage the utilization of maternal and reproductive
healthcare services among women in low-resourced
societies.
Predisposing factors
Narratives from the participants show that age is a strong
predisposing factor. For instance, Some IDI partici-
pants replied, “some young women are very fast on issues
regarding reproductive health. ey give birth in their
homes and use birth control measures such that they do
not have unwanted pregnancies”. Yet, another participant
explained, “most older women are naive, ignorant and
unconcerned about reproductive healthcare. ey feel that
they have passed the reproductive stage”. In the course of
the discussions, other participants stressed on the mari-
tal status of women. For instance, hear this participant:
Marital status cannot inuence the utilization
of maternal and reproductive healthcare. is is
because most men particularly those in the rural
areas only use their wives for entertainment. It is
the woman who bears all the pain and will decide
to adopt appropriate maternal and reproductive
healthcare services [IDI, Housewife, 37 years].
For another IDI participant, she reported: “whether you
adopt reproductive healthcare services or not, the hus-
band’s consent must be sought and prevails”. She narrated
a sad story of a friend who after two months of the fifth
child delivery, adopted birth control measures. When the
husband realized her decision, it resulted in a severe fight
that claimed the woman’s right eye.
In this regard, we see that there were contrasting views
regarding the influence of male spouses in the utiliza-
tion of maternal and reproductive health services. While
some participants were of the view that the male spouses
have no influence on maternal and reproductive health-
care utilization, others disagreed.
Interventions that can intensify optimal utilization of
maternal and reproductive healthcare services among
women in low-resourced societies
e participants gave various suggestions to promote the
utilization of maternal and reproductive healthcare ser-
vices in low-resourced societies. ey mentioned inter-
ventions including implementation of healthcare policies,
improved healthcare facilities and personnel through
capacity building, equity in the health sector categories,
mobile health services, community-based intervention
and education for low-resourced dwellers. Interventions
highlighted were categorized under two sub-themes
including government support and community-based
interventions.
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Page 8 of 12
Ene and Ajibo BMC Public Health (2023) 23:2070
Government supported interventions
Some participants suggested that they want government
legislators to implement health policies and laws that will
ensure free healthcare for all. ey emphasized that this
is greatly needed particularly for the vulnerable women
at the grass-root. For a participant, she stressed that the
implementation of health laws will ensure regular uti-
lization of health institutions. is will encourage and
increase their knowledge of available healthcare services.
Additionally, some participants explained that periodic
routine check-up exercises should be conducted in rural
communities to encourage regular healthcare utilization.
is can be done through a collaborative effort of local
leaders and health workers. See a unique quote below:
Government should institute mandatory health laws
and policies. is should be enforced with collabora-
tion from local chiefs, religious leaders, health work-
ers and security ocials. With their eort, women
can gain access to basic reproductive health services,
while knowledge of disease-causing infections and
illness can be reduced [IDI, Civil servant, 47 years].
Another suggestion raised by some participants was on
improved healthcare facilities, equity in the distribution
of funds among the three health sector categories and
ensuring personnel capacity building and training on
healthcare. Regarding these views, the majority of the
FGD participants were quick to point this out. For an
IDI participant, she responded: “knowledge can be trans-
ferred. It is simply based on what you have acquired that
you can transfer to another person”. Yet another said; “the
world is ruled by medical technology. It is then essential
that the primary healthcare facilities should be improved
like other sectors to ensure maximum service delivery”.
Other illustrative quotes include:
Health workers must indulge in regular training.
ey could go for online courses, vacation study
programs and the like. is will help increase their
knowledge on treading health technologies and
evolving diseases [IDI, Social worker, 47 years].
Seminars could be organized periodically for health
workers. is would keep them informed on current
and vital health issues. is also calls for increased
health workers, especially in rural sectors [IDI,
Housewife, 37 years].
Community-based intervention
Lastly, some participants gave suggestions on commu-
nity-based intervention through education and enlight-
enment. is becomes necessary based on the fact that
some individuals had doubts concerning the effectiveness
of certain medical technologies. Others reported that
aside from effective medical technologies, some repro-
ductive diseases can be prevented. is can be done
through adherence to health guidelines and safe medica-
tion. Below are illustrative quotes:
In this locality, some women have refused to accept
health technologies like contraceptives that will
ensure adequate wellbeing. ey belief that their
forefathers received none of these contraceptives but
they lived long. So, adopting medical technologies
and drugs will only reduce their body’s immunity.
Hence, when they need to have children, reproduc-
tion may not occur [IDI, Trader, 32 years].
e ignorance of some individuals has led to cer-
tain diseases still in existence. Community educa-
tion and enlightenment are greatly needed. is can
be done with the assistance of local Chiefs, women
leaders and health workers. Vital health knowledge
should be made available to everyone despite the
gender. is will help in dispersing health awareness
to others [IDI, Social worker, 41 years].
Assessment of the involvement of social workers in
optimizing the utilization of maternal and reproductive
healthcare services
In this regard, the resounding view was that there is little
or no knowledge about social work practitioners’ involve-
ment in healthcare settings. To use evidence in inform-
ing the involvement of social workers in this context,
we gleaned responses from the participants to under-
stand connecting narratives. For instance, a participant
responded “I do not know them and who they are”. Yet
another reported, “I have heard of one in this hospital,
but I do not know their roles here”.
Stressing on this view, the two interviewed social work-
ers explained that formal social work practice in Nige-
ria is relatively new and emerging. is implies that it is
still unpopular, especially in low-resource community
where the study was conducted. Observe these illustra-
tive quotes:
In the healthcare settings, medical social work prac-
titioners collaborate with health personnel. In this
country, the professionals face an uncertain future.
Medical social workers are being pushed to rethink
their mission and identify the practice compo-
nents and gaps needing their expertise. [IDI, Social
worker].
e roles of social workers in the health setting are
numerous. ey educate patients and families, pro-
vide care assistance, indulge in-home visits and fol-
low up in special cases. eir services are essential
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Ene and Ajibo BMC Public Health (2023) 23:2070
for quality healthcare delivery [IDI, Social worker].
Discussions
Despite the growing availability of medical technology,
modernization and government effort in the healthcare
sector, achieving optimal healthcare service utilization
remains a common problem in low and middle-income
countries, Nigeria inclusive. With an increasing popula-
tion in the country [38] and to achieve the World Health
Organization [40] initiative on safe motherhood, opti-
mizing the utilization of healthcare services becomes
paramount. Findings show that rural women in this
study abscond from utilizing institutional health facili-
ties owing to three major perceptions. First, was the per-
ception of cultural norms that assess a woman’s strength
and age based on the normal child delivery methods as
against the alternative method (cesarean operation). Sec-
ond was that their religious beliefs are against the utili-
zation of reproductive healthcare services. ird was the
mystic assumption of fear of adverse health outcomes.
ese perceptions are anchored on their decision to uti-
lize health facilities as a determinant of choice and not a
necessity. is finding is a clear indication that optimal
health facility utilization must be advocated as evidenced
by several studies [12, 18]. is will ensure early identi-
fication of ill-health, adequate treatment, and reduced
health migration; to prevent the rapid spread of illnesses
and increasing mortality.
Quite disturbing is the finding that gender marginaliza-
tion is a determinant in optimizing maternal and repro-
ductive healthcare services. is still prevails in most
African countries like Nigeria. It was found that gender
marginalization in the study locality affects women’s edu-
cational status, occupation and economic level. In this
regard, the education of females is restrained resulting in
inadequate investment by families on female education.
is discriminatory practice interacts closely with pov-
erty and consequently, hinders the opportunity of obtain-
ing good jobs and substantial income. It is important to
note that in Nigeria like some African countries, the tra-
ditional society allows inequitable gender norms which
prioritize feminine roles as wives, mothers, and house-
hold caretakers [22]. Alternatively, the education of the
girl-child is restrained to informal domestic education
at home, on hygiene, cooking, laundry and general home
management. Oftentimes, knowledge gained from the
informal setting increases their sub-optimal utilization of
health facilities. To fill the gap in maternal health, there
is a need to advocate for community-based health educa-
tion and enlightenment programs, particularly on regular
health facility utilization as suggested by [26]. is can
be done during ante-natal care services which record an
increasing number of women in attendance according to
studies by [6, 31]. is finding corroborates with existing
literatures by [1] and [20] on the essence of health edu-
cation during ante-natal care as a measure in achieving
maternal healthcare service utilization for rural women
in Nigeria.
A novel finding from this study is that the cost of ser-
vice charged in healthcare institutions poses as the most
challenging enabling factor. is is sequentially and logi-
cally true given that women are economically vulner-
able [6]. With their low economic status, they are more
likely to disregard health service utilization, particularly
in the choice of birth location, contraceptives and routine
reproductive check-ups. For example, routine reproduc-
tive health check-ups for cancer of the breast, cervical,
obstetric complications and other injuries on the repro-
ductive organs require adequate screening. ese health
issues when identified require effective counselling
and treatment. Consequently, rural women with lower
income will not afford the service charged for screen-
ing and treatment of these preventable health issues.
Evidence from arrays of literature corroborate with the
foregoing result on the under-utilization of healthcare
services owing to low income in Nigeria [28, 35, 37].
We then recommend healthcare policies implementa-
tion, equity in funding of the three categories of health
sectors and exploration of health innovations. All these
could help resolve the out-of-pocket health expenditure
and non-utilization of healthcare facilities by women in
Nigeria.
Indeed, providing medical assistance can be demand-
ing, overwhelming and challenging [14]. It is against this
background that we argue that strategizing quality mater-
nal care for optimal health utilization is essential in the
Nigerian healthcare system. We observed that another
major challenge that hindered maternal and reproductive
health service utilization was the accessibility of health
institutions. However, other need factors identified were
health providers’ incompetence, absenteeism, and negli-
gence; all anchored on the poor quality of care by health
workers. We see in a developed context, that functional
networks of care can strengthen relational linkages
between frontline health workers and provide evidence-
based maternal and reproductive care and services. It can
also provide guidance and recommendations on models
and networks of care, re-visioning the attaining of Global
Strategy for Women’s, Children and Adolescents’ Health
(WHA69.2), and strengthen private sector engagement
for Universal Health Coverage, especially in low-and
middle-income settings [41].
Our findings demonstrated that since health is an
uncompromising issue, then interventions for optimal
utilization of healthcare facilities become essential. Cor-
roborating other studies that advocated for improving
the Nigerian healthcare sector [24, 31], we observed
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Page 10 of 12
Ene and Ajibo BMC Public Health (2023) 23:2070
various suggestions that pointed to government-sup-
ported intervention. First, they suggested the implemen-
tation of health laws like health insurance policies, for
all citizens as obtained in developed countries. Second,
they reported on improved healthcare facilities by ensur-
ing equity in the primary, secondary and tertiary health
institutions. ird, participants stressed on person-
nel capacity building and training on quality healthcare
service delivery. ese strategies they highlighted will
generate programmatic-focused evidence, develop guide-
lines, norms, standards, and support regions in adapta-
tion, implementation and monitoring of person-centered
quality and respectful maternal and reproductive care. In
all, they point to the pivotal obligation of the government
and all health workers.
Another unique finding in this study that is not com-
mon in other studies is the involvement of social workers
in healthcare institutions. Quite disturbing is the find-
ing that the participants did not know of social work-
ers’ involvement in the health care setting. is could
be related to the fact that formal social work practice is
relatively new and emerging in Nigeria [25]. ese pro-
fessionals with their skills in community mobilization,
can advocate and intensify health education on early and
regular health facility visits. ey could equally organize
health programs including mobile healthcare, voluntary
care services, and follow-up home visits among other
healthcare services [3]. More so, social workers can col-
laborate with medical professionals and caregivers in
providing quality care networking for patients, particu-
larly at the grass-root. Finally, social workers are key to
galvanizing discourse sections for support networks of
family members (male spouses), through advocacy, part-
nerships, policy dialogue and capacity building [12]. is
will fill the gap in the unavailable but needed health per-
sonnel, improve the functional care system and ensure
optimal utilization of maternal and reproductive health-
care services among women in low-resourced Nigerian
settings.
Strength and limitations
e researchers first encountered difficulties in recruit-
ing respondents and participants who would volunteer
for the study. Second, the participants were all women,
selected from a particular locality. ese limitations not-
withstanding, we believe that the findings of this study
remain valid.
Conclusion
Equity in healthcare remains a core concern in attaining
universal health coverage. Rural women constitute a vul-
nerable group whose health needs should be considered
with utmost importance. is study then reveals that:
First, to ensure healthy living and promote wellbeing
for all women, healthcare service utilization becomes
paramount. is is pegged on advocating for regular uti-
lization of health facilities despite the cultural norms and
perception. is effort will ensure early identification of
health status and adequate treatment to prevent rapid
spread of the ill-health and increasing mortality.
Second, urgent attention is needed to eliminate gen-
der marginalization. Sadly, this norm prevails in most
African countries. Eliminating this discriminatory prac-
tice will not only increase the utilization of maternal and
reproductive health service but will encourage invest-
ment by families in female education and the opportunity
to obtain good jobs and substantial income.
ird, owing to our cultural norms, women are often
economically vulnerable. is challenge consequently
hinders healthcare service utilization. In this regard,
healthcare policy implementation and mainstreaming
the primary health sector (where the bulk of rural women
obtain health services) into the national health insurance
scheme will help in achieving the universal health cover-
age and the Sustainable Development Goal (SDG):3.
Lastly, healthcare assistance could also emanate from
the inclusion of medical social workers in health insti-
tutions. e collaboration of social workers with health
professionals becomes essential with the aim of providing
quality care networking for patients, particularly women
at the grass-roots.
Acknowledgements
We acknowledge that this manuscript is original and has not been submitted
elsewhere for consideration or publication. The researchers wish to
acknowledge all participants who were involved in this study.
Authors’ contributions
Jacinta Chibuzor Ene: was involved in the conceptualization of the research
topic, methodology, funding, investigation, project administration, writing
original draft, writing review and editing of the manuscript.Henry Tochukwu
Ajibo: participated in data management, design, formal analysis interpretation,
writing review and editing of original manuscript.
Funding
The research study received no funding from any agency, group or
organization in the public or commercial sectors.
Data availability
Data are stored in coded materials and databases without personal data, and
the authors have policies in place to manage and keep data secure.
All datasets generated and/or analyzed during the current study are not
publicly available due to the principle of confidentiality assured to the
participants and mode of storage (tape recording device), but are available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for the study was obtained from the institutional review
board of the Strategic Contacts Ethics Publications (STRACEP) of the University
of Nigeria, Nsukka campus, Enugu State. All methods of data collected
were carried out in accordance with relevant institutional guidelines and
regulations. The need for written informed consent was waived by the
institutional review board of the Strategic Contacts Ethics Publications
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 12
Ene and Ajibo BMC Public Health (2023) 23:2070
(STRACEP) of the University of Nigeria, Nsukka campus, Enugu State. The
justification for the waived informed consent was because it was deemed
unnecessary as the rural women volunteered to participate in the study. The
participants were informed of their freedom to withdraw at any time in the
course of the study. In all, they were assured of anonymity and confidentiality.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 27 May 2023 / Accepted: 6 October 2023
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