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Effect of Distance to Healthcare Facilities on Antenatal Care Attendance among Pregnant Women in Nigeria

Abstract

Antenatal care is an essential component of maternal healthcare because it provides pregnant women with opportunities for early identification and management of pregnancy-related complications, preventive interventions, health education, nutritional support, birth preparedness, and appropriate referral. Despite the importance of antenatal care, attendance remains inadequate among some pregnant women in Nigeria, particularly those living in rural and underserved communities. Distance to healthcare facilities is an important geographical barrier that may influence women's ability to access and consistently attend antenatal care services. Distance to healthcare facilities refers to the geographical and practical separation between a pregnant woman's place of residence and the healthcare facility where antenatal services are obtained, including physical distance, travel time, transportation availability, transportation cost, and road accessibility. Antenatal care attendance refers to pregnant women's utilization of recommended antenatal care services during pregnancy, including timing of the first visit, number of visits, continuity of attendance, and completion of recommended antenatal contacts. In Nigeria, long distances to healthcare facilities, poor road conditions, inadequate transportation, high transportation costs, and difficult terrain may discourage pregnant women from attending antenatal care regularly or may contribute to delayed initiation of care. Reduced travel burden may therefore improve access to and continuity of antenatal care. Against this background, this study investigates the effect of distance to healthcare facilities on antenatal care attendance among pregnant women in Nigeria. The study is anchored on Andersen's Behavioral Model of Health Services Use, the Health Belief Model, and the Three Delays Model. Andersen's Behavioral Model explains healthcare utilization through predisposing characteristics, enabling resources, and healthcare needs, with geographical accessibility and transportation representing important enabling factors. The Health Belief Model explains how perceived risks of pregnancy complications, perceived benefits of antenatal care, perceived barriers, and cues to action may influence women's decisions to attend antenatal services. The Three Delays Model provides a maternal-health perspective by emphasizing factors that contribute to delays in deciding to seek care, reaching an appropriate healthcare facility, and receiving adequate care after reaching the facility. Collectively, these theoretical perspectives provide a suitable framework for explaining how distance and related geographical barriers may influence antenatal care attendance among pregnant women in Nigeria. The study will adopt a quantitative cross-sectional research design. Primary data will be collected from pregnant women attending selected healthcare facilities and from pregnant women identified within selected communities in Nigeria using a structured interviewer-administered questionnaire and antenatal care attendance assessment tool. A multistage sampling technique will be employed to select states, local government areas, communities, healthcare facilities, and eligible pregnant women. Distance to healthcare facilities will be assessed using indicators such as geographical distance between residence and preferred antenatal care facility, estimated travel time, transportation availability, transportation cost, road condition, frequency of transportation, and difficulty experienced in reaching the facility. Where feasible, geographical coordinates, mapping tools, or facility records may be used to objectively estimate distance and travel time. Antenatal care attendance will be assessed using indicators such as timing of the first antenatal visit, number of antenatal visits or contacts, continuity of attendance, attendance according to recommended schedules, and completion of the recommended antenatal care contacts. Additional information will be collected on maternal age, parity, educational level, occupation, household socioeconomic characteristics, place of residence, previous pregnancy experience, and other relevant demographic and obstetric characteristics. Descriptive statistics will be used to summarize participants' characteristics, geographical accessibility, transportation conditions, and antenatal attendance patterns. Inferential statistical techniques, including chi-square tests, correlation analysis, and logistic or multiple regression analysis, will be used to determine the effect of distance to healthcare facilities on antenatal care attendance. Diagnostic tests will also be conducted to assess the reliability of the research instruments, model assumptions, goodness of fit, multicollinearity, and robustness of the findings. The study is expected to find that greater distance to healthcare facilities has a significant negative effect on antenatal care attendance among pregnant women in Nigeria. Pregnant women who live farther from healthcare facilities are expected to experience greater difficulty initiating antenatal care early, attending scheduled appointments consistently, and completing recommended antenatal care contacts. Long travel times, inadequate transportation, high transportation costs, and poor road conditions are expected to further increase the burden associated with distance and contribute to missed or delayed antenatal visits. Conversely, pregnant women who have easier physical access to healthcare facilities are expected to demonstrate better antenatal care attendance. However, distance alone may not fully determine antenatal attendance because other factors, including household income, education, perceived quality of care, availability of healthcare personnel, waiting time, cultural beliefs, family support, and affordability of services, may also influence attendance. Consequently, reducing geographical barriers should be accompanied by improvements in transportation, affordability, service availability, and quality of maternal healthcare. The study is expected to contribute to the literature on geographical healthcare accessibility, antenatal care attendance, maternal healthcare utilization, rural healthcare, maternal health, health-seeking behaviour, and public health in Nigeria by providing empirical evidence on the effect of distance to healthcare facilities on antenatal care attendance among pregnant women. The findings will provide useful information to the Federal Ministry of Health and Social Welfare, National Primary Health Care Development Agency, state ministries of health, state primary healthcare development agencies, local government health authorities, healthcare facilities, maternal-health programmes, community health workers, public health practitioners, development partners, and policymakers regarding strategies for improving access to antenatal care. The study will also provide evidence-based recommendations for strategically locating maternal healthcare facilities, strengthening community-based antenatal services, improving rural transportation and road infrastructure, reducing transportation costs, expanding outreach and mobile antenatal services, improving referral systems, and reducing geographical barriers to timely and continuous antenatal care among pregnant women in Nigeria.

Keywords: Distance to healthcare facilities, antenatal care attendance, pregnant women, Nigeria, maternal healthcare, healthcare accessibility, geographical accessibility, antenatal care, maternal health, healthcare utilization, rural healthcare, transportation barriers, health-seeking behaviour, public health.