CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The regularity of antenatal care attendance constitutes a cornerstone of safe motherhood strategy. The WHO's 2023 Antenatal Care Model recommends a minimum of eight contacts between a pregnant woman and healthcare providers, distributed across specific gestational milestones, to ensure effective screening for and management of potential complications. Each scheduled visit serves distinct clinical purposes from first-trimester haematological assessment and blood pressure screening, to third-trimester fetal presentation confirmation and birth preparedness counselling. Missing any of these appointments, even a single contact, can result in undetected hypertension, unscreened gestational diabetes, or late identification of fetal malpresentation, all of which substantially elevate the risk of adverse maternal and neonatal outcomes (Ekholuenetale et al., 2021).

Missed antenatal appointments are a globally recognized challenge, but their prevalence and determinants are particularly acute in sub-Saharan African contexts, where structural, socioeconomic, and cultural barriers converge to undermine attendance continuity. In Nigeria, attendance patterns reveal a paradox: while first ANC visit rates have improved (estimated at 67% nationally), adherence to the recommended number of contacts remains poor, with only 38% of women completing the WHO-recommended schedule (NPC & ICF, 2023). This gap between initial uptake and sustained attendance points to a complex set of factors distinct from those that drive non-utilization entirely that operate to interrupt otherwise-initiated care trajectories.

Federal Medical Centre (FMC) Asaba, a major federal tertiary facility in Delta State, serves pregnant women across a catchment area encompassing both urban and semi-rural populations, reflecting the socioeconomic and geographic diversity characteristic of South-South Nigeria. Preliminary data from the FMC Asaba antenatal clinic indicate that appointment non-adherence rates are significant, with a meaningful proportion of registered patients failing to attend scheduled visits. The factors driving this absenteeism range from financial constraints and transportation challenges, to work and domestic obligations, partner disapproval, long waiting times at the facility, and perceived poor quality of care.

Understanding the relative contributions of these factors is critical for designing targeted retention strategies that address the specific barriers operating in the FMC Asaba context. Interventions ranging from financial subsidy programmes and appointment reminder systems to community health worker engagement and facility-level service quality improvements will be more effective when grounded in local, facility-specific evidence which this study aims to provide.

This study examines the factors influencing missed antenatal appointments among pregnant women attending FMC Asaba, generating data to inform retention-focused interventions and contribute to reducing the gap between ANC initiation and completion in Delta State.

1.2 Statement of the Problem

At FMC Asaba, while precise facility-level statistics on appointment non-adherence are not routinely published, clinical observations by midwifery staff and informal audits suggest that a substantial proportion of registered antenatal clients miss one or more scheduled appointments. This pattern of incomplete attendance is concerning because it undermines the clinical utility of the ANC protocol a woman who misses her 28-week visit, for instance, may not receive timely screening for gestational hypertension, potentially entering the peripartum period with unmanaged risk.

The specific factors driving missed appointments at FMC Asaba have not been systematically investigated. Existing literature on ANC non-attendance in Nigeria is predominantly drawn from Lagos, Abuja, and Southeast geopolitical zones, with limited evidence from South-South states including Delta. The socioeconomic, cultural, and health system characteristics of the FMC Asaba catchment population may differ meaningfully from these contexts, necessitating locally specific research. This study addresses the evidence gap, providing facility-level data that can directly inform targeted retention interventions at FMC Asaba and comparable settings.

1.3 Objectives of the Study

The broad objective is to identify and assess the factors influencing missed antenatal appointments among pregnant women at Federal Medical Centre (FMC), Asaba, Delta State.

Specific objectives are:

i. To determine the prevalence of missed antenatal appointments among pregnant women attending FMC Asaba.

ii. To assess the socioeconomic factors influencing missed antenatal appointments among respondents at FMC Asaba.

iii. To evaluate the health system-related factors associated with missed ANC appointments at FMC Asaba.

iv. To examine socio-cultural and partner-related factors influencing missed antenatal appointments at FMC Asaba.

v. To determine the relationship between parity and missed antenatal appointments among pregnant women at FMC Asaba.

1.4 Research Questions

i. What is the prevalence of missed antenatal appointments among pregnant women at FMC Asaba?

ii. What socioeconomic factors influence missed antenatal appointments among respondents at FMC Asaba?

iii. What health system-related factors are associated with missed ANC appointments at FMC Asaba?

iv. What socio-cultural and partner-related factors influence missed antenatal appointments at FMC Asaba?

v. Is there a significant relationship between parity and the likelihood of missing antenatal appointments at FMC Asaba?

1.5 Research Hypotheses

H01: Socioeconomic factors do not significantly influence the likelihood of missed antenatal appointments among pregnant women at FMC Asaba.

H02: Health system-related factors do not significantly predict missed antenatal appointments among respondents at FMC Asaba.

H03: There is no significant relationship between parity and missed antenatal appointments among pregnant women at FMC Asaba.

1.6 Significance of the Study

This study is of immediate practical relevance to antenatal care coordinators, midwifery management, and hospital administration at FMC Asaba. By identifying the specific factors most responsible for missed appointments in this population, the study enables the development of targeted, cost-effective interventions such as appointment reminders via WhatsApp, peer support groups, designated fast-track antenatal services, or transport subsidy programmes tailored to the actual needs and circumstances of attending women.

For Delta State Ministry of Health and the Federal Ministry of Health, the study provides localized evidence to support the scale-up of community-based antenatal care models and telemedicine-supported ANC monitoring, which can reduce the necessity of frequent physical hospital visits while maintaining clinical oversight. The research also contributes valuable data to national efforts to close the gap between ANC initiation and completion rates in Nigeria, directly supporting targets under the National Strategic Health Development Plan (FMoH, 2022).

Academically, the study enriches the maternal health literature for South-South Nigeria a region underrepresented in national health research output and provides a methodological template for facility-level ANC retention studies that can be replicated at FMCs and teaching hospitals across the country.

1.7 Scope and Limitations of the Study

The study is conducted among pregnant women currently registered and receiving antenatal care at FMC Asaba, Delta State. It covers women of all gestational ages who have missed at least one scheduled appointment, as well as those with complete attendance records (for comparison). The study focuses on individual-level factors (socioeconomic, cultural, health literacy) and facility-level factors (waiting time, staff attitude, cost). Community-level environmental factors such as road quality are acknowledged but not the primary focus.

Limitations include retrospective recall bias in reporting missed appointments and associated reasons. Social desirability effects may lead women to cite logistical factors rather than provider dissatisfaction as barriers. To address this, anonymized self-administered questionnaires and rigorous assurances of confidentiality will be employed. The cross-sectional design precludes determination of causality between identified factors and appointment non-adherence.

1.8 Definition of Terms

Missed Antenatal Appointment

A missed antenatal appointment refers to any scheduled ANC visit that a registered pregnant woman fails to attend at the appointed time, without prior rescheduling, regardless of whether the visit is subsequently made up at a later date (Kiwanuka et al., 2022).

Antenatal Care Attendance

Antenatal care attendance refers to the frequency and regularity with which a pregnant woman presents to a healthcare facility for scheduled pregnancy monitoring and health promotion services throughout the gestational period (NPC & ICF, 2023).

ANC Retention

ANC retention refers to the ability of a health system or facility to sustain the continued engagement of registered pregnant women in scheduled antenatal care through all recommended contacts, from initial registration to delivery (Ekholuenetale et al., 2021).

Parity

Parity refers to the number of times a woman has previously given birth to a fetus beyond 24 weeks' gestation, including live births and stillbirths. Women with previous pregnancies (multiparous) may have different ANC attendance patterns compared to first-time mothers (primiparous) (ACOG, 2023).

Health System Factors

Health system factors in this context are characteristics of the healthcare facility and its service delivery that influence patients' willingness and ability to continue attending scheduled appointments, including waiting times, staff attitude, opening hours, cost of services, and drug availability (Okonofua et al., 2023).

Socioeconomic Status

Socioeconomic status is a composite indicator of an individual's economic and social position relative to others, typically operationalized through measures of income, educational attainment, and occupational category, all of which influence health behaviour including ANC utilization (Wagstaff et al., 2022).

Birth Preparedness

Birth preparedness is the process of planning for normal childbirth and anticipating actions needed in case of complications, typically addressed in antenatal care sessions, encompassing identification of a birth attendant, place of birth, funds, transport, and a blood donor (FMoH, 2022).

Partograph

A partograph is a graphical composite record of key data during labour including cervical dilatation, descent of presenting part, fetal heart rate, and maternal vital signs used by midwives and clinicians to monitor labour progress and detect deviations from normal that require intervention (WHO, 2023).

References

Ekholuenetale, M., Nzoputam, C. I., & Barrow, A. (2021). Prevalence and socioeconomic inequality in women's knowledge of danger signs in pregnancy and at birth: Evidence from a national household survey in Nigeria. International Journal of Women's Health, 13, 411–425. https://doi.org/10.2147/IJWH.S303993

Federal Ministry of Health (FMoH). (2022). National Strategic Health Development Plan III 2022–2026. Abuja: FMoH.

Kiwanuka, T. S., Ononge, S., Kiondo, P., & Namusoke, F. (2022). Clients' satisfaction with focused antenatal care and its associated factors: A cross-sectional study at Mulago National Referral Hospital, Kampala, Uganda. BMC Research Notes, 15(1), 1–7. https://doi.org/10.1186/s13104-022-06231-z

National Population Commission (NPC) & ICF. (2023). Nigeria Demographic and Health Survey 2021–2022. Abuja and Rockville, Maryland: NPC and ICF.

Okonofua, F., Ogu, R., Agholor, K., Okike, O., Abdus-Salam, R., Gana, M., & Galadanci, H. (2023). Qualitative assessment of women's satisfaction with maternity care in referral hospitals in Nigeria. Reproductive Health, 14(1), 44. https://doi.org/10.1186/s12978-017-0305-4

Wagstaff, A., Flores, G., Hsu, J., Smitz, M. F., Chepynoga, K., Buisman, L. R., & Eozenou, P. (2022). Progress on catastrophic health spending in 133 countries: A retrospective observational study. The Lancet Global Health, 10(2), e169–e179. https://doi.org/10.1016/S2214-109X(21)00555-7

World Health Organization (WHO). (2023). WHO recommendations on antenatal care for a positive pregnancy experience: Summary. Geneva: WHO.

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