title: Seeking evidence to support efforts to increase use of antenatal care: a cross-sectional study in two states of Nigeria.
abstract: BACKGROUND
  Antenatal care (ANC) attendance is a strong predictor of maternal outcomes. In Nigeria, government health planners at state level and below have limited access to population-based estimates of ANC coverage and factors associated with its use. A mixed methods study examined factors associated with the use of government ANC services in two states of Nigeria, and shared the findings with stakeholders.
  
  
  METHODS
  A quantitative household survey in Bauchi and Cross River states of Nigeria collected data from women aged 15-49 years on ANC use during their last completed pregnancy and potentially associated factors including socio-economic conditions, exposure to domestic violence and local availability of services. Bivariate and multivariate analysis examined associations with having at least four government ANC visits. We collected qualitative data from 180 focus groups of women who discussed the survey findings and recommended solutions. We shared the findings with state, Local Government Authority, and community stakeholders to support evidence-based planning.
  
  
  RESULTS
  40% of 7870 women in Bauchi and 46% of 7759 in Cross River had at least four government ANC visits. Women's education, urban residence, information from heath workers, help from family members, and household owning motorized transport were associated with ANC use in both states. Additional factors for women in Cross River included age above 18 years, being married or cohabiting, being less poor (having enough food during the last week), not experiencing intimate partner violence during the last year, and education of the household head. Factors for women in Bauchi were presence of government ANC services within their community and more than two previous pregnancies. Focus groups cited costly, poor quality, and inaccessible government services, and uncooperative partners as reasons for not attending ANC. Government and other stakeholders planned evidence-based interventions to increase ANC uptake.
  
  
  CONCLUSIONS
  Use of ANC services remains low in both states. The factors related to use of ANC services are consistent with those reported previously. Efforts to increase uptake of ANC should focus particularly on poor and uneducated women. Local solutions generated by discussion of the evidence with stakeholders could be more effective and sustainable than externally driven interventions.
authors.affiliation: CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196, South Africa. komer@ciet.org.
authors.forename: Khalid
authors.initials: K
authors.lastname: Omer
authors.affiliation: CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196, South Africa. nshadi4real@yahoo.com.
authors.forename: Nshadi John
authors.initials: NJ
authors.lastname: Afi
authors.affiliation: CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196, South Africa. muhchadibaba@yahoo.com.
authors.forename: Moh'd Chadi
authors.initials: MC
authors.lastname: Baba
authors.affiliation: CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196, South Africa. jidda085@gmail.com.
authors.forename: Maijiddah
authors.initials: M
authors.lastname: Adamu
authors.affiliation: Ministry of Health, Bauchi State Government, Bauchi, Nigeria. malamisa@yahoo.co.uk.
authors.forename: Sani Abubakar
authors.initials: SA
authors.lastname: Malami
authors.affiliation: Ministry of Health, Cross River State Government, Calabar, Nigeria. oyo_ita@yahoo.com.
authors.forename: Angela
authors.initials: A
authors.lastname: Oyo-Ita
authors.affiliation: CIET Trust Botswana, PO Box 1240, Gaborone, Botswana. acockcroft@ciet.org.
authors.forename: Anne
authors.initials: A
authors.lastname: Cockcroft
authors.affiliation: CIET-PRAM, Department of Family Medicine, McGill University, Montreal, Canada. neil@ciet.org.
authors.forename: Neil
authors.initials: N
authors.lastname: Andersson
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D003430:Cross-Sectional Studies; D003906:Developing Countries / Q000706:statistics & numerical data*; D017579:Domestic Violence; D004522:Educational Status; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys; D006266:Health Education; D006297:Health Services Accessibility; D006801:Humans; D017533:Marital Status; D008875:Middle Aged; D009549:Nigeria; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D012944:Social Support; D014186:Transportation; D014505:Urban Population; D055815:Young Adult