CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Antenatal care (ANC) is a critical component of maternal health services designed to monitor pregnancy, prevent complications, and ensure safe delivery outcomes for both mother and child. The utilization of ANC services remains a significant determinant of maternal and perinatal morbidity and mortality, particularly in low- and middle-income countries (LMICs) like Nigeria. The World Health Organization (WHO) recommends a minimum of eight ANC contacts during pregnancy to reduce maternal and neonatal mortality, yet many Nigerian women, particularly those in urban teaching hospital settings, fail to access these services adequately (WHO, 2023).

In Nigeria, the rising cost of healthcare has emerged as one of the foremost barriers to antenatal care utilization. Out-of-pocket (OOP) expenditures on health remain disproportionately high, accounting for approximately 72% of total health expenditure, far exceeding the global average of 18% (World Bank, 2022). This financial burden is particularly acute for pregnant women, who require consistent, multiple visits throughout the gestational period. At the Lagos University Teaching Hospital (LUTH), one of Nigeria's premier federal tertiary health institutions, antenatal charges including consultation fees, laboratory investigations, ultrasound services, and medications have witnessed substantial increases over recent years, directly influencing women's capacity and willingness to attend scheduled visits.

The economic landscape of Lagos State further compounds these challenges. As Nigeria's commercial capital, Lagos hosts extreme income polarization: while some residents enjoy middle-class prosperity, a significant proportion live in poverty, unable to absorb escalating healthcare costs. Studies have documented that financial constraints account for between 40% and 60% of missed ANC appointments in Nigerian tertiary hospitals (Afolabi et al., 2022; Okafor & Ihejirika, 2023). The introduction of the National Health Insurance Authority (NHIA) Act in 2022 was intended to broaden coverage, yet implementation gaps, particularly in enrolling informal sector workers and the urban poor, continue to leave large segments of the pregnant population without financial protection.

The consequences of reduced ANC utilization are severe. Inadequate antenatal care is associated with undetected hypertensive disorders of pregnancy, gestational diabetes, fetal growth restriction, and anaemia, all of which contribute to preventable maternal deaths. Nigeria continues to record one of the highest maternal mortality ratios in the world, estimated at 1,047 per 100,000 live births, and Lagos State, despite its relative wealth, records significant maternal mortality attributable to healthcare access barriers (NPC & ICF, 2023). Against this backdrop, examining the specific impact of rising healthcare costs on ANC utilization at LUTH provides valuable empirical evidence to inform health financing policy and clinical practice.

This study therefore investigates the relationship between escalating healthcare costs and the frequency and quality of antenatal care attendance among pregnant women at LUTH, Lagos, with a view to identifying actionable interventions that can improve maternal health outcomes within Nigeria's tertiary healthcare system.

1.2 Statement of the Problem

Despite widespread acknowledgment of the importance of antenatal care in reducing maternal mortality, ANC utilization rates in Nigerian tertiary hospitals remain suboptimal. At LUTH, anecdotal evidence from clinical staff and preliminary observational data suggest that a growing proportion of pregnant women attend fewer ANC sessions than recommended, or commence care at late gestational ages, frequently citing financial constraints as the primary deterrent. Rising costs of consultations, diagnostic investigations, and pharmaceutical prescriptions at the facility have reportedly escalated by 30–45% between 2020 and 2024, outpacing income growth in the target population (LUTH Annual Report, 2023).

The problem is further complicated by the inadequacy of health insurance coverage. Most pregnant women accessing LUTH are not enrolled in any formal health insurance scheme, leaving them entirely dependent on OOP payments. The resultant financial toxicity defined as the disproportionate financial burden imposed by healthcare costs disrupts the continuity of antenatal care, compromises clinical outcomes, and widens existing inequalities in maternal health. Yet empirical research specifically quantifying this relationship at LUTH remains scarce, creating an evidence gap that this study seeks to address.

1.3 Objectives of the Study

The broad objective of this study is to assess the impact of rising healthcare costs on antenatal care utilization among pregnant women at LUTH, Lagos State.

The specific objectives are:

i. To determine the pattern of antenatal care utilization among pregnant women attending LUTH.

ii. To assess the level of healthcare costs incurred by pregnant women during antenatal visits at LUTH.

iii. To examine the relationship between healthcare costs and the frequency of antenatal attendance at LUTH.

iv. To identify coping strategies employed by pregnant women in response to rising healthcare costs at LUTH.

v. To explore the role of health insurance coverage in mediating the impact of rising costs on ANC utilization at LUTH.

1.4 Research Questions

The following research questions guided this study:

i. What is the pattern of antenatal care utilization among pregnant women at LUTH?

ii. What is the level of healthcare costs incurred by pregnant women during antenatal visits at LUTH?

iii. Is there a significant relationship between healthcare costs and the frequency of antenatal attendance at LUTH?

iv. What coping strategies do pregnant women at LUTH employ in response to rising healthcare costs?

v. Does health insurance coverage moderate the impact of rising costs on ANC utilization at LUTH?

1.5 Research Hypotheses

The following hypotheses were tested in this study:

H01: There is no significant relationship between rising healthcare costs and the frequency of antenatal care attendance among pregnant women at LUTH.

H02: There is no significant difference in ANC attendance frequency between health-insured and uninsured pregnant women at LUTH.

H03: Rising healthcare costs do not significantly influence the gestational age at which pregnant women initiate antenatal care at LUTH.

1.6 Significance of the Study

This study holds significant implications for multiple stakeholders within the Nigerian health system. For policymakers, the findings will provide an evidence base for recalibrating health financing mechanisms, particularly regarding the expansion and enforcement of the NHIA Act as it applies to maternal healthcare in tertiary institutions. For hospital administrators at LUTH, the study will highlight specific cost components that deter utilization, enabling targeted fee waivers or subsidization strategies for vulnerable pregnant women.

For clinicians and midwives, the research underscores the need to integrate social and economic screening into antenatal care protocols, so that women at financial risk can be identified early and linked to available support mechanisms. Academically, the study contributes to the growing body of literature on health financing and maternal health in sub-Saharan Africa, providing data that can be generalized or compared across similar tertiary healthcare settings in Nigeria.

From a public health perspective, addressing financial barriers to ANC has a direct multiplicative effect: improving ANC attendance reduces undetected pregnancy complications, thereby lowering maternal and perinatal mortality, reducing the economic burden of emergency obstetric interventions, and contributing to the achievement of Sustainable Development Goal 3 (Good Health and Well-being).

1.7 Scope and Limitations of the Study

This study is geographically delimited to LUTH, a federal tertiary hospital located in Surulere, Lagos State. The study population comprises pregnant women of all gestational ages who are registered and attending the antenatal clinic at LUTH during the study period. The study focuses specifically on the financial dimensions of ANC utilization, excluding other potential barriers such as cultural beliefs, transportation, and provider attitudes, which are acknowledged but not the primary focus of inquiry.

Potential limitations include social desirability bias, where respondents may underreport financial challenges due to perceived stigma. Additionally, the single-site design may limit the generalizability of findings to other tertiary hospitals or primary healthcare settings in Nigeria. Retrospective recall of healthcare expenditures may also introduce recall bias. These limitations will be mitigated through the use of validated instruments, anonymization procedures, and triangulation of quantitative data with qualitative insights.

1.8 Definition of Terms

Antenatal Care (ANC)

Antenatal care refers to the systematic medical, nursing, and midwifery care provided to pregnant women from conception to the onset of labour, aimed at monitoring fetal development, detecting pregnancy complications, and promoting the health of both mother and unborn child (WHO, 2023).

Healthcare Costs

In the context of this study, healthcare costs refer to the total direct monetary expenditures incurred by pregnant women for ANC services at LUTH, including consultation fees, laboratory tests, ultrasound examinations, medications, and ancillary charges (Wagstaff et al., 2022).

ANC Utilization

ANC utilization denotes the extent to which pregnant women access and make use of recommended antenatal care services, measured by the number of ANC visits attended, the gestational age at first visit, and adherence to scheduled appointments (Exavery et al., 2021).

Out-of-Pocket Expenditure (OOP)

Out-of-pocket expenditure refers to direct payments made by individuals at the point of healthcare service delivery, not covered by any insurance scheme or government subsidy, and representing the household's own financial resources (World Bank, 2022).

Health Insurance

Health insurance is a formal financial arrangement whereby an insurer provides coverage for medical expenses incurred by an insured person in exchange for regular premium payments, thereby reducing OOP costs at the point of care (NHIA, 2022).

Financial Toxicity

Financial toxicity describes the material and psychological harm caused to patients by the financial burden of healthcare costs, including the distress, debt, and behavioural changes such as skipping appointments that result from unaffordable medical expenses (Zheng et al., 2021).

Gestational Age at First Visit

This refers to the duration of pregnancy, measured in completed weeks from the last menstrual period, at which a woman presents for her first antenatal consultation. WHO recommends first contact before 12 weeks gestation (WHO, 2023).

Tertiary Hospital

A tertiary hospital is a large, specialized health facility that provides advanced diagnostic, treatment, and referral services, typically affiliated with a university for training purposes and serving as the apex of the healthcare referral pyramid (FMoH, 2022).

References

Afolabi, B. B., Babah, O. A., & Akinajo, O. R. (2022). Determinants of antenatal care utilization in Nigeria: A systematic review. African Journal of Reproductive Health, 26(2), 45–58. https://doi.org/10.29063/ajrh2022/v26i2.5

Exavery, A., Mbaruku, G., Mbuyita, S., Makemba, A., Kinyonge, I. P., & Kweka, H. (2021). Factors affecting uptake of optimal antenatal care visits in three rural districts of Tanzania. BMC Pregnancy and Childbirth, 21(1), 1–10. https://doi.org/10.1186/s12884-021-03621-w

Federal Ministry of Health (FMoH). (2022). National Health Policy 2022–2030. Abuja: Federal Ministry of Health.

Lagos University Teaching Hospital (LUTH). (2023). Annual report and statistical bulletin. Lagos: LUTH Publications.

National Health Insurance Authority (NHIA). (2022). National Health Insurance Authority Act, 2022. Abuja: NHIA.

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

Okafor, I. P., & Ihejirika, C. E. (2023). Out-of-pocket expenditure and antenatal care attendance in Lagos tertiary hospitals. Nigerian Journal of Health Sciences, 23(1), 18–27.

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 Bank. (2022). Nigeria health financing review: Sustainable health financing for universal health coverage. Washington, D.C.: World Bank Group.

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

Zheng, Z., Han, X., Guy, G. P., Davidoff, A. J., Li, C., Banegas, M. P., & Yabroff, K. R. (2021). Do cancer survivors change their prescription drug use for financial reasons? Findings from a nationally representative sample in the United States. Cancer, 127(5), 838–846. https://doi.org/10.1002/cncr.33313

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