Provision and experience of quality antenatal care services in public primary health care facilities in Nigeria: a mixed methods study using the WHO Quality of Care framework

Provision and experience of quality antenatal care services in public primary health care facilities in Nigeria: a mixed methods study using the WHO Quality of Care framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Provision and experience of quality antenatal care services in public primary health care facilities in Nigeria: a mixed methods study using the WHO Quality of Care framework Chisom Obi-Jeff, Laila Umar, Funmilayo Oguntimehin, Abdulazeez Abdulganiyu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8701959/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Quality antenatal care (ANC) is essential for improved maternal and newborn health outcomes. Yet, providing quality ANC services remains challenging in Nigeria, with suboptimal ANC coverage and the highest global maternal deaths. Using the WHO quality of care framework, we assessed the provision and experience of quality ANC services in public primary healthcare (PHC) facilities in Nigeria and the associated determinants. Methods This convergent mixed-methods study was conducted in Anambra, Jigawa, and Kebbi states. We used a semi-structured questionnaire to conduct exit interviews with 1200 randomly sampled pregnant women accessing ANC services across 150 public PHC facilities in these states. Using semi-structured interview guides, we conducted 15 key informant interviews, 21 in-depth interviews, and 18 focus group discussions with purposively selected ANC healthcare workers (HCWs) and community members across the states. Quantitative data were analysed using descriptive statistics and logistic regression at p<0.05, and qualitative data were analysed thematically and triangulated with quantitative findings. Results Only 8.2% of participants received the recommended minimum quality of ANC services. Blood pressure measurement (76.5%) and blood testing (63.3%) were the most provided services, while tetanus vaccination (38.1%) and intestinal parasite drugs (14.0%) were the least. Satisfaction scores were 48.8-58.8% for service delivery, 46-48.8% for PHC resources adequacy, and 48.4-58.6% for interpersonal aspects of care. Free ANC services (aOR = 2.70; 95% CI: 1.5, 5.0), perceived expensive service (aOR = 3.76; 95% CI: 1.6, 8.5), urban residence (aOR = 1.72; 95% CI: 1.0, 3.0), attending ANC service due to personal choice (aOR = 1.87, 95% CI: 1.0, 3.5), accessible ANC information (aOR = 6.55, 95% CI: 1.8, 23.8; aOR = 5.95, 95% CI: 2.1, 16.8; and aOR = 8.98, 95% CI = 2.3, 33.2), and attaining primary school education (aOR = 3.18, 95% CI = 1.3, 9.9) were significantly associated with quality ANC, with long waiting times and insufficient HCWs and resources cited as major challenges. Conclusion Strengthening health systems, including recruiting and training HCWs, ensuring adequate resources, providing supportive supervision, and engaging communities, are essential to improving ANC quality. The WHO framework should also include socioeconomic factors influencing ANC provision and satisfaction. Antenatal Care Quality of Care Provision of care Experience of care People-centred ANC Access Utilisation Satisfaction Pregnant women Healthcare workers Figures Figure 1 Background Pregnancy, childbirth, and the postpartum period should be positive experiences for the health and well-being of women and their newborns [1]. However, complications during these periods remain a global concern, contributing to high maternal morbidity and mortality[1–3]. In 2023, an estimated 260,000 maternal deaths occurred worldwide due to preventable complications associated with pregnancy and childbirth [4]. Nearly 95% of these deaths were in low-and middle-income countries (LMICs), with approximately 70% occurring in sub-Saharan Africa (SSA) [5]. Nigeria accounted for 28% of all estimated global maternal deaths in 2023, with approximately 75,000 deaths, the highest rate globally and a maternal mortality ratio of 993 per 100,000 live births [4]. This underscores the inequalities in accessing and utilising quality healthcare services during pregnancy, childbirth, and postpartum [6]. Quality healthcare is a multidimensional concept that extends beyond mere service provision and traditional clinical outcomes metrics to include broader dimensions of care. Donabedian's model defines quality through structure (e.g., amenities), processes (e.g., evidence-based practices and patients’ experience), and outcome (e.g., improved health outcomes) components [7]. In addition, the Institute of Medicine identified six key dimensions of quality healthcare: safety, effectiveness, patient-centredness, timeliness, efficiency, and equity [8]. The World Health Organization's (WHO) quality of care framework for maternal and newborn health builds upon these foundational concepts, emphasising the importance of providing care and women's experiences during pregnancy and childbirth for optimal outcomes [9]. This dual focus on quality is essential in understanding and improving services, especially in the Nigerian context, where studies have shown that women's perceptions of care quality significantly influence their utilisation of maternity services, including antenatal care (ANC) [10–14]. ANC is a crucial intervention for reducing maternal and perinatal morbidity and mortality, providing opportunities to detect, prevent, and manage pregnancy-related risks, complications, or concurrent diseases while also encouraging birth preparedness and promoting health education [2,15,16]. The WHO recommends quality ANC, adopting the Institute of Medicine’s dimensions of quality healthcare definition to improve desired health outcomes [9]. To improve ANC quality, the WHO in 2016 increased the recommended number of ANC visits from a minimum of four to eight: Contact 1 in the first trimester (up to 12 weeks), Contact 2 (20 weeks) and 3 (26 weeks) in the second trimester, and Contact 4 (30 weeks), 5 (34 weeks), 6 (36 weeks), 7 (38 weeks) and 8 (40 weeks) in the third trimester [16]. Also, the 2016 ANC model emphasises the timely commencement of visits and the quality of care rather than the number of ANC visits, [16] reflecting a shift from focusing solely on the frequency of visits to ensuring meaningful and quality interactions at each contact point. This approach also aligns with evidence that the quality of care, rather than merely the number of visits, is more predictive of positive maternal and neonatal outcomes [17]. In addition, ensuring quality ANC is crucial in Nigeria, where ANC coverage is suboptimal [18], and the utilisation and access to quality ANC services are inadequate [19,20]. The quality gap in ANC is particularly pronounced in primary healthcare (PHC) facilities, which serve as the primary point of contact for most pregnant women in rural and urban slum communities [21,22]. Moreover, while traditional barriers to ANC utilization such as lack of awareness, poor geographical and physical accessibility, service availability and affordability, stockouts of essential commodities, and poor attitude and adherence to guidelines by healthcare workers (HCWs) are well-documented [23–27], evidence suggests that the quality of care is an important determinant of ANC uptake and effectiveness [10–14]. Furthermore, achieving quality of care requires essential ANC interventions delivered by skilled providers, a positive attitude from ANC providers, and the availability of infrastructure, staff, and commodities to enhance desired health outcomes at individual and facility levels [9,28]. Additionally, patients’ experiences and perceptions of quality care in health facilities influence utilisation, adherence to care, and health-seeking behaviour of others [19,29–33]. Therefore, a holistic approach is needed to assess the quality of ANC services in Nigeria, considering that merely providing quality care may not improve ANC access and utilisation if women's care experiences remain poor [34]. Several studies have assessed the quality of ANC services in Nigeria, including patients’ satisfaction with care [11,29,35,36]. However, the evidence that holistically examines the provision and women’s experience of quality care in PHC facilities using a comprehensive quality framework is limited [19,37,38]. Additionally, there is a lack of understanding regarding people-centred ANC to inform evidence-based strategies in the country [19]. Our study uses the WHO quality of care framework to assess the provision (supply) and experience (demand) of quality ANC services in public PHC facilities in Nigeria, along with their associated determinants. This dual focus will enable us to identify barriers and priority areas for intervention to enhance the quality of maternal care within Nigeria's PHC system. WHO Quality of Care Framework We used the WHO Quality of Care framework because it is a valuable tool for assessing the quality of care from the perspectives of service users and providers, thereby improving ANC services for mothers and newborns [9]. The framework conceptualises three dimensions: structure, process, and outcomes, which influence the quality of care in the health system context (see Figure 1). The structure refers to the health system’s approach to quality of care. The process includes 1) provision of care that covers evidence-based ANC practices, information systems, and functional referral systems for different levels of care, and 2) experience of care that consists of effective communication with patients, care with respect and preservation of dignity, and access to preferred social and emotional support. These dimensions cut across the availability of a skilled and motivated workforce and the infrastructure required for the desired health outcomes (people-centred outcomes and coverage of key ANC practices) at the individual and facility levels [9]. Methods Study design This study was conducted as a baseline assessment for the Optimising Client-Centered Services (OptiCCS) project in Nigeria, which aims to improve ANC uptake by ensuring that every pregnant woman attending ANC in PHCs receives quality ANC services. We used convergent mixed methods involving quantitative and qualitative methods, conducted independently and simultaneously, and then integrated them to provide a comprehensive understanding of the quality of ANC services. The quantitative method was a cross-sectional survey of women who attended ANC services, using exit interviews to assess the quality of ANC services and client satisfaction. The qualitative method was through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs) to understand factors influencing the provision and experience of quality ANC services. Study setting The study was conducted in the three purposively selected OptiCCS pilot states (Jigawa, Kebbi, and Anambra) by the National Primary Health Care Development Agency in 2023 based on ANC coverage and dropout (high and low). Across the three states, we purposively selected 15 local government areas (LGAs) (five LGAs per state), 150 wards (50 wards per state), and 50 public PHC facilities (50 PHC facilities per state). See Table 1. The PHCs were selected based on being 1) a Basic Health Care Provision Fund facility (1 PHC per ward), 2) equipped to handle ANC and delivery services, 3) an apex PHC that offers ANC and delivery services, 4) having good infrastructure and well-equipped, and 5) having essential ANC/delivery medications with a low stock-out rate. This ensures adequate coverage of the study sites to provide insights into the provision and experience of quality ANC services. Characteristics Study Sites Anambra Jigawa Kebbi Region Southeast Northwest Northwest Total population size 5,953,517 5,828,163 5,563,907 No. of LGAs 21 27 21 No. of wards 327 287 225 No. of public PHC facilities 614 749 881 ANC: At least 1 visit (skilled provider) [18] 95.5% 72.2% 41.9% ANC: At least 4 visits (any provider) [18] 93.4% 45.5% 36.8% Skilled attendance at birth [18] 95.9% 22.2% 23.3% Institutional delivery [18] 90.8% 18.2% 21.1% Table 1. Characteristics of study sites Sample size, study participants and sampling The exit interviews were conducted with pregnant women leaving the selected PHC facilities after receiving ANC services. The sample size was calculated using the sample size formula for cross-sectional studies [39]. N = Z 2 P (1-P) d 2 Where: n = minimum sample size Z= sample statistic corresponding at 95% confidence interval = 1.96 P= proportion of the population indicated overall satisfaction with maternal and child health services provided from a previous study in Nigeria (62.5%)[40] d = precision (corresponding to the effect size) at 95% confidence interval = 0.05 The adjusted sample size was 400, with an expected non-response rate of 10%. This was tripled to account for the design effect of multiple sites, yielding a sample of 1,200 women (400 per state).In each facility, we assigned each woman attending ANC at the PHC a number and then used a random number generator to select the sample to be interviewed at the end of the session. We conducted 5 KIIs, 7 IDIs, and 6 FGDs in each state, with 144 participants (48 per state). See Table 2. Level Interview type Participants No. of interviews Health facility KII Health facility In-charge 5 (1 per LGA) FGD Frontline ANC HCWs 5 (1 per LGA) Community IDI Religious leader 1 Traditional leader 1 Pregnant women 5 (1 per LGA) FGD Mothers of children under one year 1 Table 2. List of qualitative interview participants per state Participants for the qualitative interviews were purposively selected at the health facility and community levels based on their involvement in ANC programs and residency in the LGA last year, and the sample size was determined using information power [41]. They included ANC HCWs and community members (traditional and religious leaders, ward development committee [WDC] members, pregnant women who attended and did not attend ANC, and mothers of children under one year old). KIIs were conducted with the health facility in charge, and FGDs were held with frontline ANC HCWs to understand their perceptions and experiences regarding the provision of quality ANC services. IDIs were conducted with community leaders, and FGDs were held with WDC members and mothers of children under one year old to understand their perspectives on the quality of ANC services delivered at PHC facilities. IDIs were also conducted with pregnant women to understand their perceptions and experiences of the quality of ANC services received. All respondents were adults aged 18 and above and were available on the scheduled interview date. Participants were excluded if they refused to participate or did not meet the inclusion criteria. Data collection Our trained data collectors conducted the exit interviews using a pretested semi-structured questionnaire in an open data kit to eliminate the tediousness and errors associated with paper-based surveys. The trained data collectors also conducted the KIIs, IDIs, and FGDs using pretested semi-structured interview guides. All tools were developed in English, but, in some cases, the trained data collectors conducted interviews in local languages to ease communication, understanding, and active participation. Data collection was conducted in July 2023. The interview survey included questions on sociodemographic information, service provision, and satisfaction with ANC services. We collected data on the receipt of the eight most critical nationally recommended components of quality ANC services: 1) counselling/health talks including danger signs and complications during pregnancy, HIV/AIDS, birth preparedness, family planning and child spacing, diet and nutrition, prevention of mother-to-child transmission (PMTCT) of HIV/AIDS, STI, cervical cancer, and malaria in pregnancy and the use of mosquito nets, and childcare and breastfeeding; 2) intestinal parasite drugs (IPD); 3) iron/folic acid supplements; 4) malaria intermittent preventive treatment in pregnancy (IPTp); 5) Tetanus Toxoid injections; 6) blood pressure measurement; 7) urine tests; and 8) blood tests including HIV test [42]. The women’s experience of quality ANC was evaluated using 18 adapted items from a validated tool that measures client-perceived quality of ANC services, rated on a Likert scale [43,44]. The tool included satisfaction with the 1) general service; 2) quality of ANC service delivery: physical examination (e.g. weight examination, fetal heart rate, Fundal height, blood pressure measurement, obstetric ultrasound, ultrasound), diagnostics (e.g. HIV testing, blood tests, urine tests), medications (e.g. IPTp, iron supplements, IPD), vaccination (tetanus toxoid injections), and counselling/health education; 3) PHC resources: adequacy of medical equipment, consulting rooms and privacy, HCWs, and amenities; and 4) interpersonal aspect of care: compassion, respect, openness, friendliness, honesty, and the time spent with patients. After obtaining verbal consent, all exit interviews lasted between 30 and 40 minutes. Respondents who completed the exit interviews received a non-monetary incentive for their time. We conducted KIIs and IDIs at participants’ homes or offices, while the FGDs were held at a convenient location agreed upon by the participants. After obtaining verbal consent, all qualitative interviews lasted 45-60 minutes. FGD participants at the health facility and community levels were also provided stipends for travel to the interview location. No participant declined to participate in the exit and qualitative interviews. Data analysis Our primary outcome variable was ANC quality, and the explanatory variables were sociodemographic characteristics. We assessed the quality of ANC as the proportion of women who received at least the minimum acceptable level of quality ANC services, defined as the receipt of the eight most critical components/practices of ANC service provision (“good”), as reported in other studies [37,45,46]. We further assessed satisfaction as the proportion of women who were “very satisfied” with the quality of ANC service delivery, the availability of PHC resources, and the interpersonal aspects of care received during their visits to PHC facilities. The satisfaction scores were graded from very dissatisfied (1) to very satisfied (4). A descriptive analysis of the respondents’ sociodemographic characteristics, coverage of key ANC practices, and people-centred outcomes- satisfaction with ANC intervention delivery, PHC resources, and interpersonal aspects of care was conducted. The data were presented as proportions and means. Logistic regression was used to model the effect of sociodemographic characteristics on the quality of ANC services. All the variables were tested for association with the quality of ANC services using the Chi-square analysis. The multivariate logistic regression included only variables with p-values> 0.25. All variables with p-values <0.05 are considered statistically significant. Also, the variable with a variance inflation factor of 10 was excluded to avoid collinearity. All analyses were conducted in R version 4.3.0. The qualitative interviews were analysed deductively and inductively using the thematic analysis approach. We used a deductive method to develop preliminary codes and a codebook based on the domains of the quality of ANC care assessed, and an inductive approach to generate themes that emerged from the data. First, all audio-recorded interviews, including those conducted in local languages, were transcribed verbatim by external vendors and back-translated to English for validation and analysis. Second, COJ, FO, and AA randomly selected and read ten transcripts for content comprehension and familiarisation, and to generate new codes. The team compared, merged, and harmonised the codes. These codes were entered into the codebook along with their definitions and application rules. The harmonised codes underwent further review to form appropriate themes based on the data patterns, and all transcripts were coded using Deedoose version 9.0.17 (SocioCultural Research Consultants, LLC, Los Angeles, California, United States). As we read and coded subsequent transcripts, the codebook was revised until no new codes emerged. Subsequently, COJ analysed the data based on the identified themes captured within the domains of the quality of ANC care assessed and state and respondent types. Exemplary quotes were utilised for illustrative purposes and anonymised to protect respondents’ confidentiality. For integration, we used a triangulation approach by first comparing the exit and qualitative interview data and findings, followed by merging the quantitative and qualitative data during the interpretation phase to provide a comprehensive and nuanced understanding of the provision and women’s experiences of quality ANC services (as identified in the qualitative interviews) and the factors associated with acceptable quality ANC (as measured using exit interviews) in public PHCs in Nigeria. Results One thousand two hundred (1,200) pregnant women accessing ANC services across 150 PHCs participated in the exit interview. Most were married 1,154 (96.2%), reside in rural areas 1,050 (87.5%), unemployed 837 (69.8%), aged 25-34 622(51.8%), with a mean age of 26.8 years, and at a gestational age of >27weeks 472(39.3%). Regarding access to care, the majority, 944 (78.7%), had <four ANC visits, received their first ANC in the first trimester, 527 (43.9%), perceived ANC as “very accessible” 969 (80.8%), cheap 503 (41.9%), and < 30 minutes walking distance 738 (61.5%). See Table 3. Table 3. Distribution of respondents’ sociodemographic characteristics and access to care Variable Anambra n = 400 (33.3%) 1 Jigawa n = 400 (33.3%) 1 Kebbi n = 400 (33.3%) 1 Overall n = 1200 (100.0%) 1 Respondents Age < 25 years 88 (22.0%) 166 (41.5%) 154 (38.5%) 408 (34.0%) 25-34 232 (58.0%) 188 (47.0%) 202 (50.5%) 622 (51.8%) 35 years and above 80 (20.0%) 46 (11.5%) 44 (11.0%) 170 (14.2%) Gestational age 0-12 weeks 96 (24.0%) 49 (12.3%) 115 (28.8%) 260 (21.7%) 13-26 weeks 155 (38.8%) 147 (36.8%) 166 (41.5%) 468 (39.0%) 27+ weeks 149 (37.3%) 204 (51.0%) 119 (29.8%) 472 (39.3%) Marital status Formerly/never married 27 (6.8%) 11 (2.8%) 8 (2.0%) 46 (3.8%) Married 373 (93.3%) 389 (97.3%) 392 (98.0%) 1,154 (96.2%) Place of Residence Rural 324 (81.0%) 373 (93.3%) 353 (88.3%) 1,050 (87.5%) Urban 76 (19.0%) 27 (6.8%) 47 (11.8%) 150 (12.5%) Average Family Monthly Income (NGN) Less than 100,000 346 (86.5%) 387 (96.8%) 378 (94.5%) 1,111 (92.6%) 100,000 and above 54 (13.5%) 13 (3.3%) 22 (5.5%) 89 (7.4%) Education level No formal education 20 (5.0%) 161 (40.3%) 170 (42.5%) 351 (29.3%) Primary school 17 (4.3%) 74 (18.5%) 66 (16.5%) 157 (13.1%) Religious schooling only 1 (0.3%) 104 (26.0%) 94 (23.5%) 199 (16.6%) Secondary Education 292 (73.0%) 57 (14.3%) 69 (17.3%) 418 (34.8%) Tertiary education 70 (17.5%) 4 (1.0%) 1 (0.3%) 75 (6.3%) Employment status Unemployed 186 (46.5%) 338 (84.5%) 313 (78.3%) 837 (69.8%) Employed 214 (53.5%) 62 (15.5%) 87 (21.8%) 363 (30.3%) Number of ANC received Four times or more 126 (31.5%) 50 (12.5%) 80 (20.0%) 256 (21.3%) Less than 4 times 274 (68.5%) 350 (87.5%) 320 (80.0%) 944 (78.7%) First ANC Timing In the first trimester 202 (50.5%) 128 (32.0%) 197 (49.3%) 527 (43.9%) In the second trimester 153 (38.3%) 195 (48.8%) 148 (37.0%) 496 (41.3%) In the third trimester 27 (6.8%) 75 (18.8%) 44 (11.0%) 146 (12.2%) I don’t remember 18 (4.5%) 2 (0.5%) 11 (2.8%) 31 (2.6%) ANC decision Family or social pressure 66 (16.5%) 103 (25.8%) 122 (30.5%) 291 (24.3%) Health concerns or complications 103 (25.8%) 154 (38.5%) 120 (30.0%) 377 (31.4%) Personal choice or desire 230 (57.6%) 143 (35.8%) 158 (39.5%) 531 (44.3%) Accessibility of ANC services Not very accessible 5 (1.3%) 15 (3.8%) 20 (5.0%) 40 (3.3%) Somewhat accessible 34 (8.5%) 76 (19.0%) 81 (20.3%) 191 (15.9%) Very accessible 361 (90.3%) 309 (77.3%) 299 (74.8%) 969 (80.8%) Opinion on ANC service cost Cheap 288 (72.0%) 107 (26.8%) 108 (27.0%) 503 (41.9%) Expensive 40 (10.0%) 25 (6.3%) 56 (14.0%) 121 (10.1%) Free service 54 (13.5%) 206 (51.5%) 215 (53.8%) 475 (39.6%) Very expensive 18 (4.5%) 62 (15.5%) 21 (5.3%) 101 (8.4%) Distance to ANC clinic < 30 minutes of driving 39 (9.8%) 20 (5.0%) 14 (3.5%) 73 (6.1%) 2 hours of driving 1 (0.3%) 5 (1.3%) 1 (0.3%) 7 (0.6%) > 2 hours of walking 9 (2.3%) 35 (8.8%) 12 (3.0%) 56 (4.7%) Within one-hour driving 18 (4.5%) 17 (4.3%) 2 (0.5%) 37 (3.1%) Within one-hour walking 109 (27.3%) 109 (27.3%) 71 (17.8%) 289 (24.1%) 1 n (%) Provision of quality ANC A mere 8.2% (95% CI: 6.7-9.9%) received all eight critical services deemed the minimum acceptable quality of ANC, with the highest in Kebbi (14%) and lowest in Jigawa (4%). The most offered ANC service was blood pressure measurement, 918 (76.5%) (95% CI: 74.0-78.9%), followed by blood tests, 760 (63.3%) (95% CI: 60.5-66.1%). The least offered was IPD 168 (14.0%) (95% CI: 12.1-16.1%) and tetanus vaccination 457 (38.1%) (95% CI: 35.3-40.9%). In addition, the coverage of key ANC services varies across states. Less than 50% of women received IPTp 501 (41.8%) (95 % CI: 38.9-44.6%) and nutritional supplements, including iron/folic acid 532 (44.3%) (95 % CI: 41.5-47.2%). IPTp (25.3%) and counselling (46.3%) were generally lower in Jigawa than in other states (see Additional File 1). Factors associated with quality ANC provision The bivariate logistic regression analysis shows that ANC service accessibility and the perceived cost of maternity services significantly influence the quality of ANC received by pregnant women. See Table 4. Other statistically significant factors affecting ANC quality include residence type, state of residence, employment status, and ANC decision. The odds of receiving quality ANC were 24% higher among women whose decision to seek ANC was influenced by health concerns and complications than among those influenced by family and social pressure (OR = 1.24; 95% CI: 0.7, 2.1). The multiple logistics regression revealed that employed women are 49% less likely to receive good-quality ANC services than unemployed women (aOR=0.51; 95% CI: 0.3,0.9). Women who received free ANC service had 2.70 times higher odds of receiving good-quality ANC service compared with women who perceived the service as cheap (aOR = 2.70; 95% CI: 1.5, 5.0). Also, women who perceived ANC services as very expensive had 3.76 times higher odds of receiving good-quality ANC services (aOR = 3.76; 95% CI: 1.6, 8.5). The odds of women in urban areas receiving a good quality ANC service are 72% higher than those in rural settlements (aOR = 1.72; 95% CI: 1.0, 3.0). Women in Jigawa state are 71% less likely to receive good-quality ANC service than those in Anambra (OR = 0.29; 95% CI: 0.1, 0.6). See Table 4. Table 4. Predictors of quality of ANC among respondents attending ANC at public PHC facilities in Jigawa, Anambra and Kebbi states Variable Total n (%) Crude OR Adjusted OR (aOR) Poor quality, n = 1,072 1 Good quality, n = 97 1 OR 2 95% CI 2 p-value OR 2 95% CI 2 p-value Respondents Age 0.083 0.292 < 24 years* 368 (34.3%) 33 (34.0%) — — — — 25-34 549 (51.2%) 57 (58.8%) 1.16 0.7, 1.8 0.522 1.18 0.7, 1.9 0.501 35 years and above 155 (14.5%) 7 (7.2%) 0.50 0.2, 1.1 0.108 0.58 0.2, 1.3 0.229 Place of Residence 0.004 0.108 Rural* 946 (88.2%) 75 (77.3%) — — — — Urban 126 (11.8%) 22 (22.7%) 2.20 1.3, 3.6 0.002 1.72 1.0, 3.0 0.062 Employment status 0.003 0.038 Unemployed* 739 (68.9%) 80 (82.5%) — — — — Employed 333 (31.1%) 17 (17.5%) 0.47 0.3, 0.8 0.006 0.51 0.3, 0.9 0.024 ANC decision 0.039 0.153 Family or social pressure* 254 (23.7%) 25 (25.8%) — — — — Health concerns or complications 329 (30.7%) 40 (41.2%) 1.24 0.7, 2.1 0.431 1.38 0.8, 2.5 0.266 Personal choice or desire 488 (45.6%) 32 (33.0%) 0.67 0.4, 1.2 0.144 0.77 0.4, 1.4 0.376 Accessibility of ANC services <0.001 0.007 Not very accessible* 39 (3.6%) 1 (1.0%) — — — — Somewhat accessible 184 (17.2%) 4 (4.1%) 0.85 0.1, 16.8 0.884 0.79 0.1, 16.0 0.837 Very accessible 849 (79.2%) 92 (94.8%) 4.23 0.9, 75.4 0.157 3.47 0.7, 63.2 0.232 Opinion on ANC service cost <0.001 0.003 Cheap* 462 (43.1%) 22 (22.7%) — — — — Expensive 111 (10.4%) 6 (6.2%) 1.14 0.4, 2.7 0.789 0.97 0.3, 2.4 0.949 Free service 411 (38.3%) 58 (59.8%) 2.96 1.8, 5.0 <0.001 2.70 1.5, 5.0 <0.001 Very expensive 88 (8.2%) 11 (11.3%) 2.62 1.2, 5.5 0.013 3.76 1.6, 8.5 0.002 State <0.001 <0.001 Anambra* 356 (33.2%) 26 (26.8%) — — — — Jigawa 382 (35.6%) 16 (16.5%) 0.57 0.3, 1.1 0.088 0.29 0.1, 0.6 0.001 Kebbi 334 (31.2%) 55 (56.7%) 2.25 1.4, 3.7 0.001 1.40 0.8, 2.5 0.269 1 n (), *reference variable 2 OR = Odds Ratio, CI = Confidence Interval Jigawa 95 (24.0%) and Kebbi 93 (23.0%) had higher percentages of respondents with complications detected during pregnancy than Anambra 37 (9.0%). Malaria was the most reported across the three states, with the highest in Kebbi 54 (58.0%). Other complications reported were high blood pressure, severe abdominal pain, and anaemia. Women with pregnancy-related complications in Jigawa 37(39.0%), Anambra 14 (38.0%), and Kebbi 22 (24.0%) did not receive any referral due to the lack of functional emergency vehicles. Experience of quality ANC Table 5 presents women’s satisfaction with the quality of ANC service delivery, adequacy of PHC resources, and interpersonal aspects of care. Almost half of the respondents, 578 (48.2%), were “very satisfied” with the overall ANC services they received at the PHC facilities they visited. Regarding the quality of ANC service delivery, physical examinations had the highest satisfaction rate, 705(58.8%), and diagnostics had the lowest, 586 (48.8%). The satisfaction level for the available PHC resources was slightly lower than the quality of ANC services received. The percentages of respondents who were “very satisfied” with the adequacy of HCWs, consulting rooms and privacy, medical equipment, and amenities at the PHC facilities are 585 (48.8%), 572 (47.7%), 552 (46.0%), and 551 (45.9%), respectively. Respondents' responses of “very satisfied” on the interpersonal aspects of ANC ranged from 581 (48.4%) to 703 (58.6%), with HCWs’ friendliness towards patients being the highest-rated and waiting time before being attended to the lowest-rated. Table 5. Women’s satisfaction with the quality of ANC services received across the 150 PHC facilities. Question Very satisfied n (%) Satisfied n (%) Dissatisfied n (%) Very dissatisfied n (%) Mean General Satisfaction Overall level of satisfaction with the services received 578 (48.2%) 607 (50.6%) 15 (1.2%) 0 (0%) 3.5 Quality of ANC service delivery Physical examination 705 (58.8%) 461 (38.4%) 24 (2%) 10 (0.8%) 3.6 Diagnostics 586 (48.8%) 545 (45.4%) 50 (4.2%) 19 (1.6%) 3.4 Medication 621 (51.7%) 517 (43.1%) 52 (4.3%) 10 (0.8%) 3.5 Vaccination 604 (50.3%) 537 (44.8%) 45 (3.8%) 14 (1.2%) 3.4 Counselling/Health Education 673 (56.1%) 489 (40.8%) 30 (2.5%) 8 (0.7%) 3.5 Adequacy of PHC resources Medical equipment 552 (46.0%) 541 (45.1%) 88 (7.3%) 19 (1.6%) 3.4 Consulting rooms and privacy 572 (47.7%) 583 (48.6%) 36 (3%) 9 (0.8%) 3.4 Health workers 585 (48.8%) 530 (44.2%) 69 (5.8%) 16 (1.3%) 3.4 Amenities 551 (45.9%) 509 (42.4%) 100 (8.3%) 40 (3.3%) 3.3 Interpersonal aspects of care Compassion for patients 665 (55.4%) 502 (41.8%) 25 (2.1%) 8 (0.7%) 3.5 Respect for patients 666 (55.5%) 514 (42.8%) 19 (1.6%) 1 (0.1%) 3.5 Openness to patients 667 (55.6%) 512 (42.7%) 20 (1.7%) 1 (0.1%) 3.5 Friendly to patients 703 (58.6%) 466 (38.8%) 30 (2.5%) 1 (0.1%) 3.6 Honesty 656 (54.7%) 529 (44.1%) 14 (1.2%) 1 (0.1%) 3.5 Time spent explaining the health status of the child 629 (52.4%) 537 (44.8%) 31 (2.6%) 3 (0.2%) 3.5 Time devoted to patient 626 (52.2%) 537 (44.8%) 35 (2.9%) 2 (0.2%) 3.5 Waiting time 581 (48.4%) 529 (44.1%) 71 (5.9%) 19 (1.6%) 3.4 Factors associated with quality ANC experience The multiple logistics regression revealed that women in the third trimester are 66% less likely (aOR = 0.44, 95% CI: 0.2, 1.0) to receive satisfactory services during ANC visits than women in the first trimester. Those who attended the ANC service for personal reasons are 87% more likely to be satisfied with service delivery than those influenced by family and social pressure (aOR = 1.87, 95% CI: 1.0, 3.5). The odds of women being satisfied with the ANC service delivery when health information was “very available” were 6.55 times higher (aOR = 6.55, 95% CI: 1.8, 23.8) than when it was unavailable. Compared to women who perceived the service as cheap, those who felt the service was expensive were 77% less likely to be satisfied with the service received during the ANC visit (aOR = 0.23, 95% CI: 0.1, 0.6). Women from Kebbi state are 84% less likely (aOR = 0.16, 95% CI: 0.1, 0.5) to be satisfied with the service delivery than women in Anambra. See Table 6. Moreover, women who attended ANC services due to health concerns or complications are 42% less likely (OR = 0.58, 95% CI: 0.4, 1.0) to express satisfaction with the available PHC resources compared to those influenced by family and social pressure. When antenatal health information is “very available," the odds of women being satisfied with the PHC resources are 5.95 times higher (aOR = 5.95, 95% CI: 2.1, 16.8) than when it is unavailable. Compared with women in Anambra, those in Jigawa had 2.33 times higher odds of being satisfied with the PHC resources (aOR = 2.3, 95% CI: 1.4, 4.0). Refer to Table 6. The regression analysis also showed that women with primary education were 3.18 times more likely (aOR = 3.18, 95% CI = 1.3, 9.9) to be satisfied with the interpersonal care from HCWs than women without formal education. Women who reported that ANC health information was “very available” had 8.98 times higher odds (aOR = 8.98, 95% CI = 2.3, 33.2) of being satisfied with the interpersonal aspects of care compared to those who found the information “not very available”. Women in Kebbi were 0.27 times less likely (aOR = 0.27, 95% CI = 0.08, 0.79) to be satisfied with the interpersonal aspects of care than those from Anambra. Access to ANC services and residence type were associated with higher satisfaction with the interpersonal aspects of care. However, the factors were not statistically significant. See Table 6. Table 6. Predictors of women’s satisfaction with the quality of ANC services received across the 150 PHC facilities. Characteristic Quality of ANC service delivery Adequency of PHC resources Interpersonal aspects of care aOR 1 95% CI 1 p-value aOR 1 95% CI 1 p-value aOR 1 95% CI 1 p-value Gestational age 0.148 0-12 weeks* — — 13-26 weeks 0.50 0.2, 1.1 0.091 — — — — 27+ weeks 0.44 0.2, 1.0 0.047 Residence type 0.142 0.055 0.018 Rural* — — — — — — Urban 2.48 0.8, 10.8 0.151 1.83 1.0, 3.6 0.062 5.98 1.2, 108.2 0.083 Average Family Monthly Income (NGN) 0.912 0.700 0.655 100,000 and Above* — — — — — — Less than 100,000 1.06 0.4, 2.8 0.904 1.14 0.6, 2.1 0.691 1.24 0.4, 3.2 0.665 Education level 0.552 0.133 No formal* — — — — Primary school 1.04 0.5, 2.2 0.916 3.18 1.3, 9.9 0.025 Religious schooling only 1.90 0.9, 4.2 0.095 — — — 1.48 0.7, 3.1 0.294 Secondary 1.42 0.7, 3.1 0.354 — — — 1.23 0.6, 2.7 0.595 Tertiary 0.91 0.1, 18.1 0.931 0.84 0.1, 16.7 0.874 Number of ANC received 0.737 0.262 Four times or more* — — — — — Less than 4 times 0.87 0.4, 1.8 0.718 — 0.61 0.2, 1.5 0.304 ANC decision 0.130 0.006 0.182 Family or social pressure* — — — — — — Health concerns or complications 1.05 0.6, 2.0 0.869 0.58 0.4, 0.9 0.030 1.84 0.9, 3.8 0.095 Personal choice or desire 1.87 1.0, 3.5 0.050 1.15 0.7, 1.9 0.572 1.51 0.8, 2.9 0.201 Accessibility of ANC services 0.286 0.411 0.040 Not very accessible* — — — — — — Somewhat accessible 0.44 0.1, 1.6 0.227 0.49 0.2, 1.4 0.201 0.26 0.1, 1.0 0.061 Very accessible 0.76 0.2, 2.9 0.700 0.58 0.2, 1.7 0.346 0.48 0.1, 2.1 0.348 Costs of maternity services 0.011 0.607 0.232 Cheap* — — — — — — Expensive 0.44 0.2, 1.0 0.055 0.87 0.5, 1.7 0.649 0.44 0.2, 1.1 0.060 Free service 0.96 0.5, 1.8 0.901 1.00 0.6, 1.6 0.998 0.79 0.4, 1.5 0.477 Very expensive 0.23 0.1, 0.6 0.002 0.60 0.3, 1.3 0.187 1.20 0.4, 5.6 0.787 Availability of ANC health information <0.001 <0.001 <0.001 Not very available* — — — — — — Somewhat available 1.51 0.4, 5.0 0.501 0.99 0.4, 2.6 0.977 1.49 0.4, 4.9 0.518 Very available 6.55 1.8, 23.8 0.004 5.95 2.1, 16.8 <0.001 8.98 2.3, 33.2 0.001 ANC Quality 0.123 0.174 0.394 Poor* — — — — — — Good 2.99 0.9, 19.1 0.146 1.80 0.8, 4.8 0.192 1.80 0.5, 11.7 0.446 State <0.001 0.004 0.039 Anambra* — — — — — — Jigawa 0.35 0.1, 1.1 0.083 2.33 1.4, 4.0 0.002 0.36 0.1, 1.1 0.081 Kebbi 0.16 0.1, 0.5 0.002 1.25 0.8, 2.0 0.363 0.27 0.1, 0.8 0.021 1 OR = Odds Ratio, CI = Confidence Interval The qualitative interviews revealed that women’s satisfaction with ANC services was influenced by comprehensive services provided during ANC visits, including check-ups, medical tests, medications, health talks, and information. “Especially the health talk, the things they told me, how I'm supposed to be eating, what I'm supposed to eat, like fruits and other things. They told me a lot of things.” –IDI with a pregnant woman. Others include the availability of essential incentives such as routine medications, free drugs, mosquito nets, and mama kits, especially in Jigawa and Kebbi, and the friendly, compassionate, and respectful attitudes of HCWs in Anambra. “…we go to the hospital ourselves to check what is happening…and we see how they take in women with great hospitality, and give them the needed drugs, and help them.” – IDI with a Traditional leader. However, some community members were dissatisfied with HCWs' attitudes and the long waiting times during ANC services due to limited HCWs. “The problem is the lack of health workers because someone will come and wait for long, especially now that we have a high volume of women. So, we have a shortage of workers; it’s a big challenge that needs to be considered to get more staff.” – FGD with WDC. “Because a woman is pregnant, and she came to be cared for, and you are yelling at her tomorrow, she won’t come back. Also, if the patient is in your care, you are meant to talk to them well. And for a pregnant woman, you know how they are, and to come and be yelled at? No.” – FGD with WDC. Similarly, most HCWs across the states cited a shortage of HCWs, a preference for female HCWs, infrastructural decay, and frequent stock-outs of essential materials as challenges to providing quality ANC services. “ So if the government can strengthen human resources by recruiting, that is where we are lagging very far. Because some of the facilities, you know, our people have different religious beliefs…some people would think that a man is not supposed to see their spouse, so that one is a bottleneck for us. We need drugs and equipment to render the services, such as blood pressure apparatus, stethoscope, fetal stethoscope, weighing machine, height measuring scale, and examination couch .” – KII with HCW. Recommendations to improve the quality of ANC services in their communities included 1) availability of essential resources, 2) shorter waiting times, 3) more friendly HCWs, 4) health education, and 5) provision of incentives. Discussions We assessed the provision and experience of quality ANC services from the perspectives of service users and providers across 150 PHC facilities in Anambra, Kebbi, and Jigawa states, using the WHO quality of care framework and its associated factors. There is a suboptimal provision of quality ANC in Nigeria. We found that less than one-tenth (8.2%) of the women assessed received good-quality ANC. This is higher than the 7.6% in Ghana [47] and 4.6% from a 2013 nationwide population-based survey in Nigeria [37]. Conversely, our study records are lower than those obtained from other SSA, 10.9% in Kenya [48], 11.17% in six East African countries (Ethiopia, Kenya, Comoros, Madagascar, Mozambique, and Rwanda) [49], 13% in Mozambique [46], 20.3% in Nigeria [50], 29% in Zambia [51], 31.38% and 32.7% in Southern and Northern Ethiopia [45,52], and 47% in Northern Sierra Leone [53]. These differences could be attributed to 1) study design, e.g., some used a nationwide population-based survey, 2) country-specific recommended guidelines on quality ANC, and 3) facility type, e.g., tertiary, private, and primary facilities. Regardless, the poor quality of ANC provided in Nigeria, which has a large population and high maternal deaths, is alarming and a barrier to achieving Sustainable Development Goal 3. Thus, there is an urgent need to provide targeted training and supportive supervision to improve HCWs' adherence to evidence-based practices, as recommended, to ensure good-quality ANC and a positive pregnancy experience. Consistent with other studies, blood pressure measurement [37,50,51,54,55] and blood tests [46,48,50] were the most offered ANC services, while deworming medication was the least offered [37,48,50,51]. However, tetanus vaccination was not the least provided service in other countries [46,48,51]. While IPD is offered in endemic settings, the low utilisation rate of the tetanus vaccination requires efforts to increase awareness about the importance of the vaccination during ANC visits and ensure that every pregnant woman receives the vaccine. Factors significantly associated with providing quality ANC include service accessibility, the cost of maternity services, place and state of residence, employment status, and health-seeking decisions for ANC, aligning with other studies in SSA [49,56]. Women in Jigawa, including those employed, were less likely to receive good-quality ANC services. In contrast, women living in urban areas and those who received free ANC and perceived it as “very expensive” were more likely to receive good-quality ANC services. One’s place of residence has consistently been identified as a predictor of quality ANC in LMICs [57]. Those residing in urban areas tend to receive good-quality ANC than those in rural areas [37,45,49,50], which may be due to the distance to urban facilities and the availability of PHC resources in those settings, including skilled HCWs [58,59]. This calls for targeted efforts to ensure equitable access to quality ANC [9], especially in PHC facilities in rural and hard-to-reach communities. In addition, studies have shown that employed women are more likely to receive quality ANC services because they are economically empowered to pay and access care in facilities that provide higher-quality care [48,56,60]. However, we found that employed women received poor-quality ANC, while those who felt the services were expensive received good-quality ANC. While this indicates service delivery inconsistency and disparities irrespective of one’s socioeconomic status, the complex relationship between women's socioeconomic factors and the quality of ANC services in our study may be attributed to time constraints and a quality-versus-quantity trade-off. In Nigerian public PHC facilities, where long waiting times are typical [38,61–63], employed women might prioritise fewer but perceived higher-quality visits over multiple visits for convenience [64,65]. Moreover, unlike a study in Nigeria [16], the number of ANC visits in our study was not significantly associated with the likelihood of receiving better ANC. This implies that irrespective of the number of ANC visits, women in our study setting did not receive good-quality ANC, which can be attributed to inconsistent delivery of ANC services [66,67]. Additionally, the relationship between perceived cost and quality of care presents another complex dynamic. We found that free services and those considered “very expensive” were associated with higher odds of receiving good-quality ANC. The positive association between free services and good-quality care may reflect the success of government and donor-supported interventions in our study settings. Similarly, other studies have reported comparable findings in LMICs, where free maternity services led to some quality improvement and were associated with other interventions [68,69]. Also, the increased odds of receiving good quality care among women who viewed services as “very expensive” may be attributed to the psychology of perceived value, where higher costs influence quality assessment and patient satisfaction independent of actual service delivery [70,71]. However, women who perceived services as "cheap" reported lower-quality care, suggesting a quality gap in moderately priced services and the need to maintain quality standards regardless of the price to ensure equitable access to good-quality care. Future research is needed to explore how perceptions of cost influence expectations and experiences of care quality. Furthermore, nearly half of the women in our study, ranging from 24% to 39%, with pregnancy-related complications, did not receive any referral due to the lack of functional emergency vehicles. This is lower than those reported in studies in Nigeria (75%) [72] and Zimbabwe (61.7%) [73]. The lack of referral transportation systems has also been reported in Ghana and Uganda as a barrier to the referral process [74,75]. Importantly, high blood pressure, also called hypertension, was one of the major complications recorded in our study for referral, similar to that in Zimbabwe [73]. WHO recommends functional referral systems across levels of care to ensure quality ANC [9]. However, the report of some women not being referred due to a lack of resources places the mother at high risk of preterm labour and preeclampsia [76,77] and reveals the gap in services offered at the PHC level. PHC facilities must be strengthened with essential resources, including personnel and equipment, and informed by women’s and HCWs’ needs to deliver quality care and reduce maternal and perinatal outcomes. Further research and programs are needed to strengthen the health system and ensure quality ANC, as well as to improve coverage of evidence-based ANC practices and people-centred outcomes. Evidence shows that women's, their families’, and communities’ perspectives on the quality of ANC services influence health-seeking behaviour, essential to improving demand and access to quality maternal and newborn services and providing people-centred ANC [9,19,78–83]. Our study evaluated ANC satisfaction across three domains: quality of ANC service delivery, adequacy of PHC resources, and interpersonal aspects of care. The services provided in our study were highly satisfactory due to their comprehensiveness. While most women were satisfied with the availability of incentives and the friendly, compassionate, and respectful attitudes of HCWs in Anambra [29], community members, especially those in Jigawa and Kebbi, were dissatisfied with HCWs' attitudes and the long waiting times during ANC services. Studies in Nigeria have reported overall satisfaction with the quality of service [11,29,38,63] and unfavourable HCWs’ attitudes affecting ANC utilisation and encouraging home deliveries without SBA [11,38,63]. Waiting times have also persistently influenced the satisfaction and utilisation of ANC services in Nigeria [38,61–63] and other LMICs [84,85]. The long wait in our study was due to a shortage of HCWs, which could lead to burnout and poor-quality care due to the disproportionate number of clients to staff [16,84,86–88]. Slightly more than half were satisfied with the quality of ANC service delivery, particularly the physical examination and counselling/health education, but not the diagnostic tools [89]. There are varied reports on the experience of quality ANC in Nigeria. While some studies report positive perceptions [29,38,90,91], others present negative perceptions of the quality of service received [65,92]. Women in their third trimester were less likely to be satisfied with the services rendered. Also reported in Ethiopia [89], this finding indicates poor provider-client interaction, as a woman in her third trimester should have had several opportunities to establish a good relationship with HCWs and receive comprehensive care, resulting in higher satisfaction [84]. Also, women who felt the service was expensive were less satisfied, perhaps because of the displeasure of paying out of pocket, a factor also reported in other studies as contributing to low uptake and facility delivery [11,65,81,82]. This calls for a community-level health insurance scheme to enable women, particularly in rural and underserved areas, to access quality care [50]. As seen with the provision of quality ANC, place of residence was also significantly associated with service satisfaction, perhaps due to the availability of resources in these settings. Additionally, women who attended ANC services for personal reasons were satisfied with the services received during their ANC visits, consistent with findings across high-, middle-, and low-income countries [83,93]. This shows that women consider the quality of care received, as poor-quality ANC can lead to late or non-attendance [94]. Regarding the adequacy of PHC resources, less than half of our respondents were “very satisfied” with them, especially amenities and medical equipment, consistent with other studies in Nigeria [11,38,62,95,96]. Inadequate resources affect women with a positive attitude towards ANC and could result in non- or under-utilisation of services [81]. On the interpersonal aspect of care, slightly more than half of the women were “very satisfied” with the communication (i.e., time spent explaining the child’s health status, honesty, and openness to patients), respect and preservation of dignity (i.e., respect for patients), and social and emotional support (i.e., friendly to patients, time devoted to patients, and compassion for patients) similar to the findings in Kenya [48]. Conversely, poor communication, lack of respect, and abuse led to low satisfaction in Zimbabwe [84] and other LMICs [86,97]. Nevertheless, there is a need for improvement, including reducing waiting times. Women with a primary school education tend to be more satisfied with the interpersonal aspects of care. Pregnant women who have attained primary school education may lack adequate knowledge about what constitutes appropriate care experiences compared to those with secondary education or higher [84]. Additionally, across the three domains assessed, women who accessed ANC health information were more likely to be satisfied with the ANC service received. Awareness of ANC services has positively affected women’s satisfaction [76], whereas insufficient information has led to poor satisfaction levels [98]. Policymakers, program implementers, and donors must invest in patient-centred care through HCWs' education and training, supportive supervision of service provision, on-the-job mentoring, and the implementation of a service delivery and consumer protection initiative, such as SERVICOM, across all public PHC facilities to obtain feedback from women accessing ANC services for continuous quality improvement. There is also a need to strengthen social accountability at the community level by engaging communities to identify barriers to ANC utilisation, co-design feasible and culturally appropriate solutions, implement and monitor them, and hold policymakers and program implementers accountable for quality public service. Our findings both validate and extend the WHO quality of care framework in the Nigerian context. While our results align with the framework's “provision of care” and “experience of care” domains, they also reveal critical gaps. The study highlights deficiencies in clinical service delivery and women's satisfaction, particularly regarding essential ANC components, waiting times, and HCWs’ attitudes. Importantly, our research underscores the significant influence of socioeconomic factors, notably income levels and employment, on ANC provision and experience, elements not explicitly addressed in the current framework. This suggests a need to expand the WHO framework to more robustly incorporate economic considerations, such as service costs and women's financial status, which impact ANC access and satisfaction. Enhancing the framework with these socioeconomic dimensions could improve its applicability across diverse settings, similar to Nigeria. However, further research is needed to comprehensively assess how the framework might be expanded to address other contextual factors influencing ANC quality and experience across various settings. Limitations We had limitations worth mentioning. First, our study settings were purposively selected, which could limit the generalisability of our findings. However, the number of PHCs assessed provided valuable insights into ANC practices, showcasing areas for improvement in the quality of ANC, its utilisation, and maternal health outcomes. Our use of exit interviews eliminates observation bias, allowing these women to respond regarding the provision and satisfaction of the care they received. Second, we did not survey women who did not visit the PHC facilities. Still, we compensated for this by including them in the qualitative interviews. We also did not assess information systems within the PHC services due to our data collection source [99]. An observation is needed to determine the functionality of health information systems in public PHC facilities. Conclusions The quality of ANC for pregnant women accessing ANC services in public PHC facilities is found to be suboptimal in our study. We identified that factors such as service costs and living in the facility's location influence the provision of good-quality ANC. Although the overall satisfaction with the care received was high, there are clear areas for improvement, including diagnosis, adequacy of HCWs, facility conditions- consulting rooms and privacy, medical equipment and amenities, and interpersonal aspects of care. Our study strongly supports the need to assess the quality of ANC, from the provision and the experience of care, to identify areas for improvement and reduce maternal morbidity and mortality. We recommend investment in health systems strengthening, including recruiting and training HCWs on providing women-centred care and ANC interventions according to the recommended standards and guidelines, available and adequate resources, supportive supervision of practice, and engaging communities and families to reduce equity gaps, promote positive pregnancy experience, and improve the quality of care and maternal and newborn outcomes. List of Abbreviations ANC: Antenatal care FGD: Focus group discussions HCW: Health workers IDI: In-depth interviews IPD: Intestinal Parasite Drugs IPTp: Intermittent preventive treatment in pregnancy KIIs: Key Informant Interviews LGA: Local Government Areas LMICs: Low-income and middle-income countries NHREC: National Health Research Ethics Committee OptiCCS: Optimising Client-Centred Services PMTCT: Prevention of mother-to-child transmission SBA: Skilled Birth Attendants SSA: sub-Saharan Africa WDC: Ward Development Committee WHO: World Health Organisation Declarations Ethical approval and consent to participate We obtained ethical approval for the study from the National Health Research Ethics Committee of Nigeria (NHREC), NHREC/01/01/2007-04/07/2023. The assessment was conducted in accordance with NHREC’s guidelines and regulations. In addition, we used a standard oral consent script approved by NHREC to secure consent from all individuals interviewed. The consent script outlined the participants' consent to participate in the study, their confidentiality, protection from harm, and permission to record the interview for analytical purposes. Consent for publication Not applicable Availability of data and materials The dataset generated and analysed during this study is included in this published article and available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by BACKUP Health, a global program of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, commissioned by the German Federal Ministry for Economic Cooperation and Development based on a project piloted by GIZ BACKUP Health. The funders had no role in the conceptualisation, study design, data collection, analysis, interpretation, decision to publish or manuscript writing. Authors’ contributions COJ designed the mixed-method study, developed the data collection tools and the analysis plan, supported the qualitative interview coding, interpreted the survey and qualitative analysis, and drafted the manuscript. LU, CE, AD, ZH, and OU reviewed the data collection tools. LU reviewed the manuscript. FO supervised the data collection and coded the qualitative interviews. Abduljaleel Adejumo conducted the survey analysis. Abdulazeez Abdulganiyu coded the qualitative interviews. EE reviewed the analysis and the manuscript. All authors read and approved the final manuscript for submission and agreed to be accountable for their contributions, ensuring that all questions regarding the accuracy or integrity of the work, even those unrelated to them, are investigated, resolved, and documented in the literature. Acknowledgements We appreciate the leadership of NPHCDA, the Department of Community Health Services, and the leaders and program managers of the Anambra, Jigawa, and Kebbi Primary Health Care Development Agency for their support during the study. We also recognise the support of the ANC HCWs from the 150 PHCs and the community members at the study sites. Additionally, we thank Rachael Olorupo, our state-based coordinators, and data collectors for facilitating the data collection across the sites. References World Health Organization. World health statistics 2023: monitoring health for the SDGs, Sustainable Development Goals. Geneva; 2023. Khatri RB, Mengistu TS, Assefa Y. Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence. BMC Pregnancy Childbirth. 2022 Dec 28;22(1):977. Cresswell JA, Alexander M, Chong MYC, Link HM, Pejchinovska M, Gazeley U, et al. 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Why rural women do not use primary health centres for pregnancy care: evidence from a qualitative study in Nigeria. BMC Pregnancy Childbirth. 2019 Dec 5;19(1):277. Ademuyiwa IY, Opeke RO, Odetola TD. Utilisation of antenatal care services as determinants of satisfaction and its challenges in Lagos, Nigeria. Br J Midwifery. 2020 Apr 2;28(4):242–50. Ademuyiwa IY, Opeke RO, Farotimi AA, Ejidokun A, Olowe AO, Ojo EA. Awareness and satisfaction with antenatal care services among pregnant women in Lagos state, Nigeria. Calabar J Health Sci. 2021 Jun 30;5:21. Fagbamigbe AF, Idemudia ES. Barriers to antenatal care use in Nigeria: evidences from non-users and implications for maternal health programming. BMC Pregnancy Childbirth. 2015 Dec 17;15(1):95. Okonofua F, Imosemi D, Igboin B, Adeyemi A, Chibuko C, Idowu A, et al. Maternal death review and outcomes: An assessment in Lagos State, Nigeria. PLoS One. 2017 Dec 14;12(12):e0188392. Banke-Thomas A, Avoka CKO, Gwacham-Anisiobi U, Omololu O, Balogun M, Wright K, et al. Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study. BMJ Glob Health [Internet]. 2022 Apr 1 [cited 2022 Nov 24];7(4):e008604. Available from: https://gh.bmj.com/content/7/4/e008604 Gamberini C, Angeli F, Ambrosino E. Exploring solutions to improve antenatal care in resource-limited settings: an expert consultation. BMC Pregnancy Childbirth. 2022 Dec 30;22(1):449. Onyeonoro U, Ukegbu A, Emelumadu O, Ezeama N, Ifeadike C, Okezie O. Perception of quality of maternal healthcare services among women utilising antenatal services in selected primary health facilities in Anambra State, Southeast Nigeria. Nigerian Medical Journal. 2014;55(2):148. Oyovwe P, Woolhead G. Exploring health care professionals’ and women’s perspectives on the barriers to maternal health services: a qualitative study in Eku Town of Delta State, Nigeria. AIMS Public Health. 2021;8(1):154–71. Okonofua F, Ogu R, Agholor K, Okike O, Abdus-salam R, Gana M, et al. Qualitative assessment of women’s satisfaction with maternal health care in referral hospitals in Nigeria. Reprod Health. 2017 Dec 16;14(1):44. Idris S, Sambo M, Ibrahim M. Barriers to utilisation of maternal health services in a semi-urban community in northern Nigeria: The clients′ perspective. Nigerian Medical Journal. 2013;54(1):27. Azuh D, Azuh A, Iweala E, Adeloye D, Akanbi M, Mordi R. Factors influencing maternal mortality among rural communities in southwestern Nigeria. Int J Womens Health. 2017 Apr;Volume 9:179–88. Umar N, Quaife M, Exley J, Shuaibu A, Hill Z, Marchant T. Toward improving respectful maternity care: a discrete choice experiment with rural women in northeast Nigeria. BMJ Glob Health. 2020 Mar 5;5(3):e002135. Azodoh VN. Quality of antenatal care services in selected primary health care centers in the Federal Capital Territory(FCT), Nigeria. The Anatolian Journal of Family Medicine. 2020; Oyekale AS. Assessment of primary health care facilities’ service readiness in Nigeria. BMC Health Serv Res. 2017 Dec 1;17(1):172. Fagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: Evidence from a population-based survey. Reprod Health [Internet]. 2015 Sep 18 [cited 2023 Apr 7];12(1):1–9. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-015-0081-0 Nwaeze IL, Enabor OO, Oluwasola TAO, Aimakhu CO. PERCEPTION AND SATISFACTION WITH QUALITY OF ANTENATAL CARE SERVICES AMONG PREGNANT WOMEN AT THE UNIVERSITY COLLEGE HOSPITAL. Ann Ib Postgrad Med. 2013 Jun;11(1):22–8. Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench [Internet]. 2013 [cited 2021 Dec 15];6(1):14. Available from: /pmc/articles/PMC4017493/ Tesleem K. B, Ifeoma P. O. 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Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251382 Duong D Van, Binns C, … AL… J for Q in, 2004 undefined. Measuring client-perceived quality of maternity services in rural Vietnam. academic.oup.com [Internet]. [cited 2023 Apr 8]; Available from: https://academic.oup.com/intqhc/article-abstract/16/6/447/1805865 Tadesse Berehe T, Modibia LM. Assessment of Quality of Antenatal Care Services and Its Determinant Factors in Public Health Facilities of Hossana Town, Hadiya Zone, Southern Ethiopia: A Longitudinal Study. Adv Public Health. 2020 Aug 17;2020:1–11. Reis-Muleva B, Vilela Borges AL, Simões Duarte L, da Silva dos Santos CC, de Castro Nascimento N. Assessment of the quality of antenatal care in Mozambique. Midwifery. 2023 Mar;118:103598. Amponsah-Tabi S, Dassah ET, Asubonteng GO, Ankobea F, Annan JJK, Senu E, et al. An assessment of the quality of antenatal care and pregnancy outcomes in a tertiary hospital in Ghana. 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Quality of Prenatal Care and Associated Factors among Pregnant Women at Public Health Facilities of Wogera District, Northwest Ethiopia. J Pregnancy. 2020 Jan 29;2020:1–8. Koroma MM, Kamara SS, Bangura EA, Kamara MA, Lokossou V, Keita N. The quality of free antenatal and delivery services in Northern Sierra Leone. Health Res Policy Syst. 2017 Jul 12;15(S1):49. Kanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub–Saharan Africa: Evidence from nationally representative health facility assessments. J Glob Health. 2024 May 23; Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Health. 2018 Apr 12;3(2):e000779. Afulani PA. Rural/Urban and Socioeconomic Differentials in Quality of Antenatal Care in Ghana. PLoS One. 2015 Feb 19;10(2):e0117996. Demissie DB, Molla G, Tiruneh Tiyare F, Badacho AS, Tadele A. Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis. SAGE Open Med. 2024 Jan 9;12. Majrooh MA, Hasnain S, Akram J, Siddiqui A, Memon ZA. Coverage and Quality of Antenatal Care Provided at Primary Health Care Facilities in the ‘Punjab’ Province of ‘Pakistan.’ PLoS One. 2014 Nov 19;9(11):e113390. World Health Organisation. Sexual and Reproductive Health. Maternal Health in Nigeria: Generating Information for Action. [Internet]. 2019 [cited 2024 May 24]. Available from: https://www.who.int/news/item/25-06-2019-maternal-health-in-nigeria-generating-information-for-action Joshi C, Torvaldsen S, Hodgson R, Hayen A. Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data. BMC Pregnancy Childbirth. 2014 Dec 3;14(1):94. Asekun-olarinmoye EO, Bamidele JO, Egbewale BE, Asekun-Olarinmoye IO, Ojofeitimi EO. 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Creanga AA, Gullo S, Kuhlmann AKS, Msiska TW, Galavotti C. Is quality of care a key predictor of perinatal health care utilization and patient satisfaction in Malawi? BMC Pregnancy Childbirth. 2017 Dec 22;17(1):150. Ewunetie AA, Munea AM, Meselu BT, Simeneh MM, Meteku BT. DELAY on first antenatal care visit and its associated factors among pregnant women in public health facilities of Debre Markos town, North West Ethiopia. BMC Pregnancy Childbirth. 2018 Dec 16;18(1):173. Oyugi B, Kendall S, Peckham S. Effects of free maternal policies on quality and cost of care and outcomes: an integrative review. Prim Health Care Res Dev. 2021 Sep 15;22:e43. Dennis ML, Abuya T, Campbell OMR, Benova L, Baschieri A, Quartagno M, et al. Evaluating the impact of a maternal health voucher programme on service use before and after the introduction of free maternity services in Kenya: a quasi-experimental study. BMJ Glob Health. 2018 May 2;3(2):e000726. Uzochukwu B, Onwujekwe O, Akpala C. Community satisfaction with the quality of maternal and child health services in Southeast Nigeria. East Afr Med J. 2004 Oct 22;81(6). Onyeonoro U, Ukegbu A, Emelumadu O, Ezeama N, Ifeadike C, Okezie O. Perception of quality of maternal healthcare services among women utilising antenatal services in selected primary health facilities in Anambra State, Southeast Nigeria. Nigerian Medical Journal. 2014;55(2):148. Banke-Thomas A, Avoka C, Olaniran A, Balogun M, Wright O, Ekerin O, et al. Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria’s most urbanised state. Soc Sci Med. 2021 Dec;291:114492. Busumani W, Mundagowa PT. Outcomes of pregnancy-related referrals from rural health facilities to two central hospitals in Harare, Zimbabwe: a prospective descriptive study. BMC Health Serv Res. 2021 Dec 25;21(1):276. Daniels AA, Abuosi A. Improving emergency obstetric referral systems in low and middle income countries: a qualitative study in a tertiary health facility in Ghana. BMC Health Serv Res. 2020 Dec 10;20(1):32. Nabulo H, Gottfredsdottir H, Joseph N, Kaye DK. Experiences of referral with an obstetric emergency: voices of women admitted at Mbarara Regional Referral Hospital, South Western Uganda. BMC Pregnancy Childbirth. 2023 Jul 6;23(1):498. FARAHI N, OLUYADI F, DOTSON AB. Hypertensive Disorders of Pregnancy. Am Fam Physician. 2024 Mar;109(3):251–60. American College of Obstetricians and Gynecologists. Preeclampsia and high blood pressure during pregnancy. [Internet]. 2020 [cited 2024 May 24]. Available from: https://www.acog.org/womens-health/faqs/Preeclampsia-and-High-Blood-Pressure-During-Pregnancy?utm_source=redirect&utm_medium=web&utm_campaign=otn Yaya S, Bishwajit G, Uthman OA, Amouzou A. Why some women fail to give birth at health facilities: A comparative study between Ethiopia and Nigeria. PLoS One. 2018 May 3;13(5):e0196896. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth. 2015 Dec 18;15(1):97. Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria - looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009 Dec 15;9(1):43. Finlayson K, Downe S. Why Do Women Not Use Antenatal Services in Low- and Middle-Income Countries? A Meta-Synthesis of Qualitative Studies. PLoS Med. 2013 Jan 22;10(1):e1001373. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014 Dec 19;11(1):71. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Provision and uptake of routine antenatal services: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews. 2019 Jun 12;2019(6). Hibusu L, Sumankuuro J, Gwelo NB, Akintola O. Pregnant women’s satisfaction with the quality of antenatal care and the continued willingness to use health facility care in Lusaka district, Zambia. BMC Pregnancy Childbirth. 2024 Jan 2;24(1):20. Gong E, Dula J, Alberto C, de Albuquerque A, Steenland M, Fernandes Q, et al. Client experiences with antenatal care waiting times in southern Mozambique. BMC Health Serv Res. 2019 Dec 1;19(1):538. Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Global Health. 2015 Dec 15;11(1):36. Sumankuuro J, Crockett J, Wang S. The use of antenatal care in two rural districts of Upper West Region, Ghana. PLoS One. 2017 Sep 28;12(9):e0185537. Akintola O, Hlengwa WM, Dageid W. Perceived stress and burnout among volunteer caregivers working in AIDS care in South Africa. J Adv Nurs. 2013 Dec 19;69(12):2738–49. Emiru AA, Alene G, Debelew GT. Women’s satisfaction with the quality of antenatal care services rendered at public health facilities in Northwest Ethiopia: the application of partial proportional odds model. BMJ Open. 2020 Sep 17;10(9):e037085. Titilayo O, Oyewole O, Chidera A, Omosuzi M. Perception and level of satisfaction with the quality of antenatal care services among pregnant women attending antenatal clinic at plateau state specialist hospital, Jos, Nigeria. Afr Health Sci. 2023 Sep;23(3). Sayyadi BM, Gajida AU, Garba R, Ibrahim UM. Assessment of maternal health services: a comparative study of urban and rural primary health facilities in Kano State, Northwest Nigeria. Pan Afr Med J. 2021;38:320. Ajibola I, Israel OK, Akande RO. Access, Perceived Quality and Uptake of Antenatal Services in Urban Communities of Osun State, Southwest Nigeria. Afr J Reprod Health. 2022;26(12):78–89. van Pelt S, van der Pijl M, A.C. Ruiter R, Ndaki PM, Kilimba R, Shields-Zeeman L, et al. Pregnant women’s perceptions of antenatal care and utilisation of digital health tools in Magu District, Tanzania: a qualitative study. Sex Reprod Health Matters. 2023 Dec 31;31(1). Gross K, Alba S, Glass TR, Schellenberg JA, Obrist B. Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania. BMC Pregnancy Childbirth. 2012 Dec 21;12(1):16. Ekenna A, Itanyi IU, Nwokoro U, Hirschhorn LR, Uzochukwu B. How ready is the system to deliver primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria. Health Policy Plan. 2020 Nov 1;35(Supplement_1):i97–106. Aghaji A, Burchett HED, Oguego N, Hameed S, Gilbert C. Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems. BMC Health Serv Res. 2021 Dec 20;21(1):1360. Afulani PA, Phillips B, Aborigo RA, Moyer CA. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. Lancet Glob Health. 2019 Jan;7(1):e96–109. Alemayehu A. Quality of Antenatal Care Service in Public Health Facilities of Chencha District, Gamo Gofa Zone, Southern Ethiopia. Women’s Health. 2017 Feb 21;4(3). World Health Organization. QUALITY OF CARE FOR MATERNAL AND NEWBORN HEALTH: A MONITORING FRAMEWORK FOR NETWORK COUNTRIES. 2019 Feb. Additional Declarations No competing interests reported. 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framework","fulltext":[{"header":"Background","content":"\u003cp\u003ePregnancy, childbirth, and the postpartum period should be positive experiences for the health and well-being of women and their newborns [1]. However, complications during these periods remain a global concern, contributing to high maternal morbidity and mortality[1\u0026ndash;3]. In 2023, an estimated 260,000 maternal deaths occurred worldwide due to preventable complications associated with pregnancy and childbirth [4].\u0026nbsp;Nearly 95% of these deaths were in low-and middle-income countries (LMICs), with approximately 70% occurring in sub-Saharan Africa (SSA) [5]. Nigeria accounted for 28% of all estimated global maternal deaths in 2023, with approximately 75,000 deaths, the highest rate globally and a maternal mortality ratio of 993 per 100,000 live births [4].\u0026nbsp;This underscores the inequalities in accessing and utilising quality healthcare services during pregnancy, childbirth, and postpartum [6].\u003c/p\u003e\n\u003cp\u003eQuality healthcare is a multidimensional concept that extends beyond mere service provision and traditional clinical outcomes metrics to include broader dimensions of care. Donabedian\u0026apos;s model defines quality through structure (e.g., amenities), processes (e.g., evidence-based practices and patients\u0026rsquo; experience), and outcome (e.g., improved health outcomes) components [7]. In addition, the Institute of Medicine identified six key dimensions of quality healthcare: safety, effectiveness, patient-centredness, timeliness, efficiency, and equity [8]. The World Health Organization\u0026apos;s (WHO) quality of care framework for maternal and newborn health builds upon these foundational concepts, emphasising the importance of providing care and women\u0026apos;s experiences during pregnancy and childbirth for optimal outcomes [9]. This dual focus on quality is essential in understanding and improving services, especially in the Nigerian context, where studies have shown that women\u0026apos;s perceptions of care quality significantly influence their utilisation of maternity services, including antenatal care (ANC)\u0026nbsp;[10\u0026ndash;14].\u003c/p\u003e\n\u003cp\u003eANC is a crucial intervention for reducing maternal and perinatal morbidity and mortality, providing opportunities to detect, prevent, and manage pregnancy-related risks, complications, or concurrent diseases while also encouraging birth preparedness and promoting health education [2,15,16]. The WHO recommends quality ANC, adopting the Institute of Medicine\u0026rsquo;s dimensions of quality healthcare definition to improve desired health outcomes [9]. To improve ANC quality, the WHO in 2016 increased the recommended number of ANC visits from a minimum of four to eight: Contact 1 in the first trimester (up to 12 weeks), Contact 2 (20 weeks) and 3 (26 weeks) in the second trimester, and Contact 4 (30 weeks), 5 (34 weeks), 6 (36 weeks), 7 (38 weeks) and 8 (40 weeks) in the third trimester [16]. Also, the 2016 ANC model emphasises the timely commencement of visits and the quality of care rather than the number of ANC visits, [16] reflecting a shift from focusing solely on the frequency of visits to ensuring meaningful and quality interactions at each contact point.\u0026nbsp;This approach also aligns with evidence that the quality of care, rather than merely the number of visits, is more predictive of positive maternal and neonatal outcomes [17].\u003c/p\u003e\n\u003cp\u003eIn addition, ensuring quality ANC is crucial in Nigeria, where ANC coverage is suboptimal [18], and the utilisation and access to quality ANC services are inadequate [19,20]. The quality gap in ANC is particularly pronounced in primary healthcare (PHC) facilities, which serve as the primary point of contact for most pregnant women in rural and urban slum communities [21,22]. Moreover, while traditional barriers to ANC utilization such as lack of awareness, poor geographical and physical accessibility, service availability and affordability, stockouts of essential commodities, and poor attitude and adherence to guidelines by healthcare workers (HCWs) are well-documented [23\u0026ndash;27], evidence suggests that the quality of care is an important determinant of ANC uptake and effectiveness [10\u0026ndash;14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, achieving quality of care requires essential ANC interventions delivered by skilled providers, a positive attitude from ANC providers, and the availability of infrastructure, staff, and commodities to enhance desired health outcomes at individual and facility levels [9,28]. Additionally, patients\u0026rsquo; experiences and perceptions of quality care in health facilities influence utilisation, adherence to care, and \u0026nbsp;health-seeking behaviour of others [19,29\u0026ndash;33]. Therefore, a holistic approach is needed to assess the quality of ANC services in Nigeria, considering that merely providing quality care may not improve ANC access and utilisation if women\u0026apos;s care experiences remain poor [34].\u003c/p\u003e\n\u003cp\u003eSeveral studies have assessed the quality of ANC services in Nigeria, including patients\u0026rsquo; satisfaction with care [11,29,35,36]. However, the evidence that holistically examines the provision and women\u0026rsquo;s experience of quality care in PHC facilities using a comprehensive quality framework is limited [19,37,38]. Additionally, there is a lack of understanding regarding people-centred ANC to inform evidence-based strategies in the country [19]. Our study uses the WHO quality of care framework to assess the provision (supply) and experience (demand) of quality ANC services in public PHC facilities in Nigeria, along with their associated determinants. This dual focus will enable us to identify barriers and priority areas for intervention to enhance the quality of maternal care within Nigeria\u0026apos;s PHC system.\u003c/p\u003e\n\u003ch2\u003eWHO Quality of Care Framework\u003c/h2\u003e\n\u003cp\u003eWe used the WHO Quality of Care framework because it is a valuable tool for assessing the quality of care from the perspectives of service users and providers, thereby improving ANC services for mothers and newborns [9]. The framework conceptualises three dimensions: structure, process, and outcomes, which influence the quality of care in the health system context (see Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003estructure\u003c/em\u003e refers to the health system\u0026rsquo;s approach to quality of care. The \u003cem\u003eprocess\u003c/em\u003e includes 1) \u003cstrong\u003eprovision of care\u003c/strong\u003e that covers evidence-based ANC practices, information systems, and functional referral systems for different levels of care, and 2) \u003cstrong\u003eexperience of care\u003c/strong\u003e that consists of effective communication with patients, care with respect and preservation of dignity, and access to preferred social and emotional support. These dimensions cut across the availability of a skilled and motivated workforce and the infrastructure required for the desired health \u003cem\u003eoutcomes\u003c/em\u003e (people-centred outcomes and coverage of key ANC practices) at the individual and facility levels [9].\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThis study was conducted as a baseline assessment for the Optimising Client-Centered Services (OptiCCS) project in Nigeria, which aims to improve ANC uptake by ensuring that every pregnant woman attending ANC in PHCs receives quality ANC services. We used convergent mixed methods involving quantitative and qualitative methods, conducted independently and simultaneously, and then integrated them to provide a comprehensive understanding of the quality of ANC services. The quantitative method was a cross-sectional survey of women who attended ANC services, using exit interviews to assess the quality of ANC services and client satisfaction. The qualitative method was through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs) to understand factors influencing the provision and experience of quality ANC services.\u003c/p\u003e\n\u003ch2\u003eStudy setting\u003c/h2\u003e\n\u003cp\u003eThe study was conducted in the three purposively selected OptiCCS pilot states (Jigawa, Kebbi, and Anambra) by the National Primary Health Care Development Agency in 2023 based on ANC coverage and dropout (high and low). Across the three states, we purposively selected 15 local government areas (LGAs) (five LGAs per state), 150 wards (50 wards per state), and 50 public PHC facilities (50 PHC facilities per state). See Table 1. The PHCs were selected based on being 1) a Basic Health Care Provision Fund facility (1 PHC per ward), 2) equipped to handle ANC and delivery services, 3) an apex PHC that offers ANC and delivery services, 4) having good infrastructure and well-equipped, and 5) having essential ANC/delivery medications with a low stock-out rate. This ensures adequate coverage of the study sites to provide insights into the provision and experience of quality ANC services.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Sites\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnambra\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eJigawa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKebbi\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSoutheast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorthwest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorthwest\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal population size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,953,517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,828,163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,563,907\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo. of LGAs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo. of wards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo. of public PHC facilities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e749\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e881\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eANC: At least 1 visit (skilled provider)\u0026nbsp;[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eANC: At least 4 visits (any provider)\u0026nbsp;[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSkilled attendance at birth\u0026nbsp;[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInstitutional delivery\u0026nbsp;[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1. Characteristics of study sites\u003c/p\u003e\n\u003ch2\u003eSample size, study participants and sampling\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe exit interviews were conducted with pregnant women leaving the selected PHC facilities after receiving ANC services. The sample size was calculated using the sample size formula for cross-sectional studies [39].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN = \u003cu\u003eZ\u003csup\u003e2\u003c/sup\u003eP (1-P)\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; d\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhere:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003en = minimum sample size\u003c/li\u003e\n \u003cli\u003eZ= sample statistic corresponding at 95% confidence interval = 1.96\u003c/li\u003e\n \u003cli\u003eP= proportion of the population indicated overall satisfaction with maternal and child health services provided from a previous study in Nigeria (62.5%)[40]\u003c/li\u003e\n \u003cli\u003ed = precision (corresponding to the effect size) at 95% confidence interval = 0.05\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe adjusted sample size was 400, with an expected non-response rate of 10%. This was tripled to account for the design effect of multiple sites, yielding a sample of 1,200 women (400 per state).In each facility, we assigned each woman attending ANC at the PHC a number and then used a random number generator to select the sample to be interviewed at the end of the session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe conducted 5 KIIs, 7 IDIs, and 6 FGDs in each state, with 144 participants (48 per state). See Table 2.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of interviews\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth facility In-charge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (1 per LGA)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFrontline ANC HCWs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (1 per LGA)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eIDI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReligious leader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional leader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePregnant women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (1 per LGA)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMothers of children under one year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. List of qualitative interview participants per state\u003c/p\u003e\n\u003cp\u003eParticipants for the qualitative interviews were purposively selected at the health facility and community levels based on their involvement in ANC programs and residency in the LGA last year, and the sample size was determined using information power [41]. They included ANC HCWs and community members (traditional and religious leaders, ward development committee [WDC] members, pregnant women who attended and did not attend ANC, and mothers of children under one year old). KIIs were conducted with the health facility in charge, and FGDs were held with frontline ANC HCWs to understand their perceptions and experiences regarding the provision of quality ANC services. IDIs were conducted with community leaders, and FGDs were held with WDC members and mothers of children under one year old to understand their perspectives on the quality of ANC services delivered at PHC facilities. IDIs were also conducted with pregnant women to understand their perceptions and experiences of the quality of ANC services received. All respondents were adults aged 18 and above and were available on the scheduled interview date. Participants were excluded if they refused to participate or did not meet the inclusion criteria.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eOur trained data collectors conducted the exit interviews using a pretested semi-structured questionnaire in an open data kit to eliminate the tediousness and errors associated with paper-based surveys. The trained data collectors also conducted the KIIs, IDIs, and FGDs using pretested semi-structured interview guides. All tools were developed in English, but, in some cases, the trained data collectors conducted interviews in local languages to ease communication, understanding, and active participation. Data collection was conducted in July 2023.\u003c/p\u003e\n\u003cp\u003eThe interview survey included questions on sociodemographic information, service provision, and satisfaction with ANC services. We collected data on the receipt of the eight most critical nationally recommended components of quality ANC services: 1) counselling/health talks including danger signs and complications during pregnancy, HIV/AIDS, birth preparedness, family planning and child spacing, \u0026nbsp;diet and nutrition, prevention of mother-to-child transmission (PMTCT) of HIV/AIDS, STI, cervical cancer, and malaria in pregnancy and the use of mosquito nets, and childcare and breastfeeding; 2) intestinal parasite drugs (IPD); 3) iron/folic acid supplements; 4) malaria intermittent preventive treatment in pregnancy (IPTp); 5) Tetanus Toxoid injections; 6) blood pressure measurement; 7) urine tests; and 8) blood tests including HIV test [42]. \u0026nbsp;The women’s experience of quality ANC was evaluated using 18 adapted items from a validated tool that measures client-perceived quality of ANC services, rated on a Likert scale [43,44]. The tool included satisfaction with the 1) general service; 2) quality of ANC service delivery: physical examination (e.g. weight examination, fetal heart rate, Fundal height, blood pressure measurement, obstetric ultrasound, ultrasound), diagnostics (e.g. HIV testing, blood tests, urine tests), medications (e.g. IPTp, iron supplements, IPD), vaccination (tetanus toxoid injections), and counselling/health education; 3) PHC resources: adequacy of medical equipment, consulting rooms and privacy, HCWs, and amenities; and 4) interpersonal aspect of care: compassion, respect, openness, friendliness, honesty, and the time spent with patients. After obtaining verbal consent, all exit interviews lasted between 30 and 40 minutes. Respondents who completed the exit interviews received a non-monetary incentive for their time.\u003c/p\u003e\n\u003cp\u003eWe conducted KIIs and IDIs at participants’ homes or offices, while the FGDs were held at a convenient location agreed upon by the participants. After obtaining verbal consent, all qualitative interviews lasted 45-60 minutes. FGD participants at the health facility and community levels were also provided stipends for travel to the interview location. No participant declined to participate in the exit and qualitative interviews.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eOur primary outcome variable was ANC quality, and the explanatory variables were sociodemographic characteristics. We assessed the quality of ANC as the proportion of women who received at least the minimum acceptable level of quality ANC services, defined as the receipt of the eight most critical components/practices of ANC service provision (“good”), as reported in other studies [37,45,46]. We further assessed satisfaction as the proportion of women who were “very satisfied” with the quality of ANC service delivery, the availability of PHC resources, and the interpersonal aspects of care received during their visits to PHC facilities. The satisfaction scores were graded from very dissatisfied (1) to very satisfied (4). A descriptive analysis of the respondents’ sociodemographic characteristics, coverage of key ANC practices, and people-centred outcomes- satisfaction with ANC intervention delivery, PHC resources, and interpersonal aspects of care was conducted. The data were presented as proportions and means. Logistic regression was used to model the effect of sociodemographic characteristics on the quality of ANC services. All the variables were tested for association with the quality of ANC services using the Chi-square analysis. The multivariate logistic regression included only variables with p-values\u0026gt; 0.25. All variables with p-values \u0026lt;0.05 are considered statistically significant. Also, the variable with a variance inflation factor of 10 was excluded to avoid collinearity. All analyses were conducted in R version 4.3.0.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative interviews were analysed deductively and inductively using the thematic analysis approach. We used a deductive method to develop preliminary codes and a codebook based on the domains of the quality of ANC care assessed, and an inductive approach to generate themes that emerged from the data. First, all audio-recorded interviews, including those conducted in local languages, were transcribed verbatim by external vendors and back-translated to English for validation and analysis. Second, COJ, FO, and AA randomly selected and read ten transcripts for content comprehension and familiarisation, and to generate new codes. The team compared, merged, and harmonised the codes. These codes were entered into the codebook along with their definitions and application rules. The harmonised codes underwent further review to form appropriate themes based on the data patterns, and all transcripts were coded using Deedoose version 9.0.17 (SocioCultural Research Consultants, LLC, Los Angeles, California, United States). As we read and coded subsequent transcripts, the codebook was revised until no new codes emerged. Subsequently, COJ analysed the data based on the identified themes captured within the domains of the quality of ANC care assessed and state and respondent types. Exemplary quotes were utilised for illustrative purposes and anonymised to protect respondents’ confidentiality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor integration, we used a triangulation approach by first comparing the exit and qualitative interview data and findings, followed by merging the quantitative and qualitative data during the interpretation phase to provide a comprehensive and nuanced understanding of the provision and women’s experiences of quality ANC services (as identified in the qualitative interviews) and the factors associated with acceptable quality ANC (as measured using exit interviews) in public PHCs in Nigeria.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOne thousand two hundred (1,200) pregnant women accessing ANC services across 150 PHCs participated in the exit interview. Most were married 1,154 (96.2%), reside in rural areas 1,050 (87.5%), unemployed\u0026nbsp;837 (69.8%),\u0026nbsp;aged 25-34 622(51.8%), with a mean age of 26.8 years, and at a gestational age of \u0026gt;27weeks\u0026nbsp;472(39.3%).\u0026nbsp;Regarding access to care, the majority, 944 (78.7%), had \u0026lt;four ANC visits, received their first ANC in the first trimester, 527 (43.9%), perceived ANC as \u0026ldquo;very accessible\u0026rdquo; 969 (80.8%), cheap 503 (41.9%), and \u0026lt; 30 minutes walking distance 738 (61.5%). See Table 3.\u003c/p\u003e\n\u003cp\u003eTable 3. Distribution of respondents\u0026rsquo; sociodemographic characteristics and access to care\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAnambra\u003cbr\u003e n = 400 (33.3%)\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eJigawa\u003cbr\u003e n = 400 (33.3%)\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKebbi\u003cbr\u003e n = 400 (33.3%)\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003cbr\u003e n = 1200 (100.0%)\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRespondents Age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 25 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e166 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e154 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e408 (34.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e25-34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e232 (58.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e188 (47.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e202 (50.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e622 (51.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e35 years and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (11.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e170 (14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e0-12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e96 (24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49 (12.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e115 (28.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e260 (21.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e13-26 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e155 (38.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e147 (36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e166 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e468 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e27+ weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e149 (37.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e204 (51.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e119 (29.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e472 (39.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFormerly/never married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e373 (93.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e389 (97.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e392 (98.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1,154 (96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of Residence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e324 (81.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e373 (93.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e353 (88.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1,050 (87.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e150 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAverage Family Monthly Income (NGN)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLess than 100,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e346 (86.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e387 (96.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e378 (94.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1,111 (92.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e100,000 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (5.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e89 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e161 (40.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e170 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e351 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74 (18.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e157 (13.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReligious schooling only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104 (26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e199 (16.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSecondary Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e292 (73.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69 (17.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e418 (34.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTertiary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e186 (46.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e338 (84.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e313 (78.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e837 (69.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e214 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87 (21.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e363 (30.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of ANC received\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFour times or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e126 (31.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e256 (21.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLess than 4 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e274 (68.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e350 (87.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e320 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e944 (78.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFirst ANC Timing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIn the first trimester\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e202 (50.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e128 (32.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e197 (49.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e527 (43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIn the second trimester\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e153 (38.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e195 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e148 (37.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e496 (41.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIn the third trimester\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (11.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e146 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI don\u0026rsquo;t remember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eANC decision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFamily or social pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103 (25.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e122 (30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e291 (24.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHealth concerns or complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103 (25.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e154 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e120 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e377 (31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePersonal choice or desire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e230 (57.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e143 (35.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e158 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e531 (44.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAccessibility of ANC services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNot very accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSomewhat accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e191 (15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVery accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e361 (90.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e309 (77.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e299 (74.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e969 (80.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOpinion on ANC service cost\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCheap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e288 (72.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e107 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e108 (27.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e503 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExpensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e121 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFree service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e206 (51.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e215 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e475 (39.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVery expensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e101 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDistance to ANC clinic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 30 minutes of driving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 30 minutes of walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e224 (56.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e214 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300 (75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e738 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt; 2 hours of driving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt; 2 hours of walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWithin one-hour driving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWithin one-hour walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e109 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e109 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71 (17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e289 (24.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e n (%)\u003c/p\u003e\n\u003ch2\u003eProvision of quality ANC\u003c/h2\u003e\n\u003cp\u003eA mere 8.2% (95% CI: 6.7-9.9%) received all eight critical services deemed the minimum acceptable quality of ANC, with the highest in Kebbi (14%) and lowest in Jigawa (4%). The most offered ANC service was blood pressure measurement, 918 (76.5%) (95% CI: 74.0-78.9%), followed by blood tests, 760 (63.3%) (95% CI: 60.5-66.1%). The least offered was IPD 168 (14.0%) (95% CI: 12.1-16.1%) and tetanus vaccination 457 (38.1%) (95% CI: 35.3-40.9%). In addition, the coverage of key ANC services varies across states. Less than 50% of women received IPTp 501 (41.8%) (95 % CI: 38.9-44.6%) and nutritional supplements, including iron/folic acid 532 (44.3%) (95 % CI: 41.5-47.2%). IPTp (25.3%) and counselling (46.3%) were generally lower in Jigawa than in other states (see Additional File 1).\u003c/p\u003e\n\u003ch3\u003eFactors associated with quality ANC provision\u003c/h3\u003e\n\u003cp\u003eThe bivariate logistic regression analysis shows that ANC service accessibility and the perceived cost of maternity services significantly influence the quality of ANC received by pregnant women. See Table 4. Other statistically significant factors affecting ANC quality include residence type, state of residence, employment status, and ANC decision. The odds of receiving quality ANC were 24% higher among women whose decision to seek ANC was influenced by health concerns and complications than among those influenced by family and social pressure (OR = 1.24; 95% CI: 0.7, 2.1).\u003c/p\u003e\n\u003cp\u003eThe multiple logistics regression revealed that employed women are 49% less likely to receive good-quality ANC services than unemployed women (aOR=0.51; 95% CI: 0.3,0.9). Women who received free ANC service had 2.70 times higher odds of receiving good-quality ANC service compared with women who perceived the service as cheap (aOR = 2.70; 95% CI: 1.5, 5.0). Also, women who perceived ANC services as very expensive had 3.76 times higher odds of receiving good-quality ANC services (aOR = 3.76; 95% CI: 1.6, 8.5). The odds of women in urban areas receiving a good quality ANC service are 72% higher than those in rural settlements (aOR = 1.72; 95% CI: 1.0, 3.0). Women in Jigawa state are 71% less likely to receive good-quality ANC service than those in Anambra (OR = 0.29; 95% CI: 0.1, 0.6). See Table 4.\u003c/p\u003e\n\u003cp\u003eTable 4. Predictors of quality of ANC among respondents attending ANC at public PHC facilities in Jigawa, Anambra and Kebbi states\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"704\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrude OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted OR (aOR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor quality,\u003c/p\u003e\n \u003cp\u003en = 1,072\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood quality,\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;n = 97\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOR\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOR\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRespondents Age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 24 years*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e368 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33 (34.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e549 (51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57 (58.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.501\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 years and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e155 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.229\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of Residence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e946 (88.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75 (77.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e126 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3, 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0, 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnemployed*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e739 (68.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80 (82.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e333 (31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3, 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3, 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eANC decision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFamily or social pressure*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e254 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (25.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth concerns or complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e329 (30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8, 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePersonal choice or desire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e488 (45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (33.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccessibility of ANC services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot very accessible*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSomewhat accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e184 (17.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.884\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.837\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e849 (79.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92 (94.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9, 75.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 63.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpinion on ANC service cost\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCheap*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e462 (43.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e111 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3, 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFree service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e411 (38.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58 (59.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8, 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5, 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery expensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88 (8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.2, 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.6, 8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eState\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnambra*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e356 (33.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJigawa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e382 (35.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3, 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKebbi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e334 (31.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55 (56.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.4, 3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8, 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.269\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e n (), *reference variable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e OR = Odds Ratio, CI = Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eJigawa 95 (24.0%) and Kebbi 93 (23.0%) had higher percentages of respondents with complications detected during pregnancy than Anambra 37 (9.0%). Malaria was the most reported across the three states, with the highest in Kebbi 54 (58.0%). Other complications reported were high blood pressure, severe abdominal pain, and anaemia. Women with pregnancy-related complications in Jigawa 37(39.0%), Anambra 14 (38.0%), and Kebbi 22 (24.0%) did not receive any referral due to the lack of functional emergency vehicles.\u003c/p\u003e\n\u003ch2\u003eExperience of quality ANC\u003c/h2\u003e\n\u003cp\u003eTable 5 presents women\u0026rsquo;s satisfaction with the quality of ANC service delivery, adequacy of PHC resources, and interpersonal aspects of care. Almost half of the respondents,\u0026nbsp;578 (48.2%), were \u0026ldquo;very satisfied\u0026rdquo; with the overall ANC services they received at the PHC facilities they visited. Regarding the quality of ANC service delivery, physical examinations had the highest satisfaction rate, 705(58.8%), and diagnostics had the lowest, 586 (48.8%). The satisfaction level for the available PHC resources was slightly lower than the quality of ANC services received. The percentages of respondents who were \u0026ldquo;very satisfied\u0026rdquo; with the adequacy of HCWs, consulting rooms and privacy, medical equipment, and amenities at the PHC facilities are 585 (48.8%), 572 (47.7%), 552 (46.0%), and 551 (45.9%), respectively. Respondents\u0026apos; responses of \u0026ldquo;very satisfied\u0026rdquo; on the interpersonal aspects of ANC ranged from 581 (48.4%) to 703 (58.6%), with HCWs\u0026rsquo; friendliness towards patients being the highest-rated and waiting time before being attended to the lowest-rated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5. Women\u0026rsquo;s satisfaction with the quality of ANC services received across the 150 PHC facilities.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVery satisfied\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSatisfied\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDissatisfied n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVery dissatisfied\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral Satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall level of satisfaction with the services received\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e578 (48.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e607 (50.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of ANC service delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical examination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e705 (58.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e461 (38.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnostics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e586 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e545 (45.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e621 (51.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e517 (43.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVaccination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e604 (50.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e537 (44.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCounselling/Health Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e673 (56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e489 (40.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequacy of PHC resources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e552 (46.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e541 (45.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsulting rooms and privacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e572 (47.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e583 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e585 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e530 (44.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Amenities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e551 (45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e509 (42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpersonal aspects of care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCompassion for patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e665 (55.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e502 (41.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRespect for patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e666 (55.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e514 (42.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOpenness to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e667 (55.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e512 (42.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFriendly to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e703 (58.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e466 (38.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHonesty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e656 (54.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e529 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime spent explaining the health status of the child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e629 (52.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e537 (44.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime devoted to patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e626 (52.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e537 (44.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWaiting time\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e581 (48.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e529 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eFactors associated with quality ANC experience\u003c/h3\u003e\n\u003cp\u003eThe multiple logistics regression revealed that women in the third trimester are 66% less likely (aOR = 0.44, 95% CI:\u0026nbsp;0.2, 1.0) to receive satisfactory services during ANC visits than women in the first trimester.\u0026nbsp;Those who attended the ANC service for personal reasons are 87% more likely to be satisfied with service delivery than those influenced by family and social pressure (aOR = 1.87, 95% CI: 1.0, 3.5). The odds of women being satisfied with the ANC service delivery when health information was \u0026ldquo;very available\u0026rdquo; were 6.55 times higher (aOR = 6.55, 95% CI: 1.8, 23.8) than when it was unavailable.\u0026nbsp;Compared to women who perceived the service as cheap, those who felt the service was expensive were 77% less likely to be satisfied with the service received during the ANC visit (aOR = 0.23, 95% CI:\u0026nbsp;0.1, 0.6). Women from Kebbi state are 84% less likely (aOR = 0.16, 95% CI:\u0026nbsp;0.1, 0.5) to be satisfied with the service delivery than women in Anambra. See Table 6.\u003c/p\u003e\n\u003cp\u003eMoreover, women who attended ANC services due to health concerns or complications are 42% less likely (OR = 0.58, 95% CI: 0.4, 1.0) to express satisfaction with the available PHC resources compared to those influenced by family and social pressure. When antenatal health information is \u0026ldquo;very available,\u0026quot; the odds of women being satisfied with the PHC resources are 5.95 times higher (aOR = 5.95, 95% CI: 2.1, 16.8) than when it is unavailable. Compared with women in Anambra, those in Jigawa had 2.33 times higher odds of being satisfied with the PHC resources (aOR = 2.3, 95% CI:\u0026nbsp;1.4, 4.0). Refer to Table 6.\u003c/p\u003e\n\u003cp\u003eThe regression analysis also showed that\u0026nbsp;women with primary education were 3.18 times more likely (aOR = 3.18, 95% CI = 1.3, 9.9) to be satisfied with the interpersonal care from HCWs than women without formal education. Women who reported that ANC health information was \u0026ldquo;very available\u0026rdquo; had 8.98 times higher odds (aOR = 8.98, 95% CI = 2.3, 33.2) of being satisfied with the interpersonal aspects of care compared to those who found the information \u0026ldquo;not very available\u0026rdquo;. Women in Kebbi were 0.27 times less likely (aOR = 0.27, 95% CI = 0.08, 0.79) to be satisfied with the interpersonal aspects of care than those from Anambra. Access to ANC services and residence type were associated with higher satisfaction with the interpersonal aspects of care. However, the factors were not statistically significant. See Table 6.\u003c/p\u003e\n\u003cp\u003eTable 6. Predictors of women\u0026rsquo;s satisfaction with the quality of ANC services received across the 150 PHC facilities.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of ANC service delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequency of PHC resources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpersonal aspects of care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0-12 weeks*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13-26 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27+ weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.047\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8, 10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0, 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.2, 108.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage Family Monthly Income (NGN)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.912\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.655\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100,000 and Above*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLess than 100,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.904\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6, 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.691\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.665\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo formal*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5, 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.916\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3, 9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReligious schooling only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9, 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.294\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6, 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.931\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.874\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of ANC received\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFour times or more*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLess than 4 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.718\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eANC decision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFamily or social pressure*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth concerns or complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6, 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.869\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9, 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePersonal choice or desire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0, 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.050\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7, 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8, 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccessibility of ANC services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.040\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot very accessible*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSomewhat accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery accessible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.348\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCosts of maternity services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.607\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCheap*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5, 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.649\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2, 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFree service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5, 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.901\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6, 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.477\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery expensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3, 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability of ANC health information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot very available*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSomewhat available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4, 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.518\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8, 23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.1, 16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.3, 33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eANC Quality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.394\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9, 19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8, 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5, 11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.446\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eState\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.039\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnambra*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJigawa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.4, 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKebbi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8, 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.363\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1, 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e OR = Odds Ratio, CI = Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe qualitative interviews revealed that women\u0026rsquo;s satisfaction with ANC services was influenced by comprehensive services provided during ANC visits, including check-ups, medical tests, medications, health talks, and information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Especially the health talk, the things they told me, how I\u0026apos;m supposed to be eating, what I\u0026apos;m supposed to eat, like fruits and other things. They told me a lot of things.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash;IDI with a pregnant woman.\u003c/p\u003e\n\u003cp\u003eOthers include the availability of essential incentives such as routine medications, free drugs, mosquito nets, and mama kits, especially in Jigawa and Kebbi, and the friendly, compassionate, and respectful attitudes of HCWs in Anambra.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;we go to the hospital ourselves to check what is happening\u0026hellip;and we see how they take in women with great hospitality, and give them the needed drugs, and help them.\u0026rdquo;\u003c/em\u003e \u0026ndash; IDI with a Traditional leader.\u003c/p\u003e\n\u003cp\u003eHowever, some community members were dissatisfied with HCWs\u0026apos; attitudes and the long waiting times during ANC services due to limited HCWs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The problem is the lack of health workers because someone will come and wait for long, especially now that we have a high volume of women. So, we have a shortage of workers; it\u0026rsquo;s a big challenge that needs to be considered to get more staff.\u0026rdquo;\u003c/em\u003e \u0026ndash; FGD with WDC.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because a woman is pregnant, and she came to be cared for, and you are yelling at her tomorrow, she won\u0026rsquo;t come back.\u0026nbsp;\u003c/em\u003e\u003cem\u003eAlso, if the patient is in your care, you are meant to talk to them well. And for a pregnant woman, you know how they are, and to come and be yelled at? No.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; FGD with WDC.\u003c/p\u003e\n\u003cp\u003eSimilarly, most HCWs across the states cited a shortage of HCWs, a preference for female HCWs, infrastructural decay, and frequent stock-outs of essential materials as challenges to providing quality ANC services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSo if the government can strengthen human resources by recruiting, that is where we are lagging very far. Because some of the facilities, you know, our people have different religious beliefs\u0026hellip;some people would think that a man is not supposed to see their spouse, so that one is a bottleneck for us. We need drugs and equipment to render the services, such as blood pressure apparatus, stethoscope, fetal stethoscope, weighing machine, height measuring scale, and examination couch\u003c/em\u003e.\u0026rdquo; \u0026ndash; KII with HCW.\u003c/p\u003e\n\u003cp\u003eRecommendations to improve the quality of ANC services in their communities included 1) availability of essential resources, 2) shorter waiting times, 3) more friendly HCWs, 4) health education, and 5) provision of incentives.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eWe assessed the provision and experience of quality ANC services from the perspectives of service users and providers across 150 PHC facilities in Anambra, Kebbi, and Jigawa states, using the WHO quality of care framework and its associated factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is a suboptimal provision of quality ANC in Nigeria. We found that less than one-tenth (8.2%) of the women assessed received good-quality ANC. This is higher than the 7.6% in Ghana [47] and 4.6% from a 2013 nationwide population-based survey in Nigeria [37].\u0026nbsp;Conversely, our study records are lower than those obtained from other SSA, 10.9% in Kenya [48], 11.17% in six East African countries (Ethiopia, Kenya, Comoros, Madagascar, Mozambique, and Rwanda) [49], 13% in Mozambique [46], 20.3% in Nigeria [50], 29% in Zambia [51], 31.38% and 32.7% in Southern and Northern Ethiopia [45,52], and 47% in Northern Sierra Leone [53]. These differences could be attributed to 1) study design, e.g., some used a nationwide population-based survey, 2) country-specific recommended guidelines on quality ANC, and 3) facility type, e.g., tertiary, private, and primary facilities. Regardless, the poor quality of ANC provided in Nigeria, which has a large population and high maternal deaths, is alarming and a barrier to achieving Sustainable Development Goal 3. Thus, there is an urgent need to provide targeted training and supportive supervision to improve HCWs' adherence to evidence-based practices, as recommended, to ensure good-quality ANC and a positive pregnancy experience.\u003c/p\u003e\n\u003cp\u003eConsistent with other studies, blood pressure measurement [37,50,51,54,55] and blood tests [46,48,50]\u0026nbsp;were the most offered ANC services, while deworming medication was the least offered [37,48,50,51]. However, tetanus vaccination was not the least provided service in other countries [46,48,51]. While IPD is offered in endemic settings, the low utilisation rate of the tetanus vaccination requires efforts to increase awareness about the importance of the vaccination during ANC visits and ensure that every pregnant woman receives the vaccine.\u003c/p\u003e\n\u003cp\u003eFactors significantly associated with providing quality ANC include service accessibility, the cost of maternity services, place and state of residence, employment status, and health-seeking decisions for ANC, aligning with other studies in SSA \u0026nbsp;[49,56]. Women in Jigawa, including those employed, were less likely to receive good-quality ANC services. In contrast, women living in urban areas and those who received free ANC and perceived it as “very expensive” were more likely to receive good-quality ANC services. One’s place of residence has consistently been identified as a predictor of quality ANC in LMICs [57]. Those residing in urban areas tend to receive good-quality ANC than those in rural areas [37,45,49,50], which may be due to the distance to urban facilities and the availability of PHC resources in those settings, including skilled HCWs [58,59]. This calls for targeted efforts to ensure equitable access to quality ANC\u0026nbsp;[9], especially in PHC facilities in rural and hard-to-reach communities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, studies have shown that employed women are more likely to receive quality ANC services because they are economically empowered to pay and access care in facilities that provide higher-quality care [48,56,60]. However, we found that employed women received poor-quality ANC, while those who felt the services were expensive received good-quality ANC. While this indicates service delivery inconsistency and disparities irrespective of one’s socioeconomic status, the complex relationship between women's socioeconomic factors and the quality of ANC services in our study may be attributed to time constraints and a quality-versus-quantity trade-off. In Nigerian public PHC facilities, where long waiting times are typical\u0026nbsp;[38,61–63], employed women might prioritise fewer but perceived higher-quality visits over multiple visits for convenience [64,65]. Moreover, unlike a study in Nigeria [16], the number of ANC visits in our study was not significantly associated with the likelihood of receiving better ANC. This implies that irrespective of the number of ANC visits, women in our study setting did not receive good-quality ANC, which can be attributed to inconsistent delivery of ANC services [66,67].\u003c/p\u003e\n\u003cp\u003eAdditionally, the relationship between perceived cost and quality of care presents another complex dynamic. We found that free services and those considered “very expensive” were associated with higher odds of receiving good-quality ANC. The positive association between free services and good-quality care may reflect the success of government and donor-supported interventions in our study settings. Similarly, other studies have reported comparable findings in LMICs, where free maternity services led to some quality improvement and were associated with other interventions [68,69]. Also, the increased odds of receiving good quality care among women who viewed services as “very expensive” may be attributed to the psychology of perceived value, where higher costs influence quality assessment and patient satisfaction independent of actual service delivery [70,71]. However, women who perceived services as \"cheap\" reported lower-quality care, suggesting a quality gap in moderately priced services and the need to maintain quality standards regardless of the price to ensure equitable access to good-quality care. Future research is needed to explore how perceptions of cost influence expectations and experiences of care quality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, nearly half of the women in our study, ranging from 24% to 39%, with pregnancy-related complications, did not receive any referral due to the lack of functional emergency vehicles. This is lower than those reported in studies in Nigeria (75%) [72] and Zimbabwe (61.7%) [73]. The lack of referral transportation systems has also been reported in Ghana and Uganda as a barrier to the referral process [74,75]. Importantly, high blood pressure, also called hypertension, was one of the major complications recorded in our study for referral, similar to that in Zimbabwe [73]. WHO recommends functional referral systems across levels of care to ensure quality ANC [9].\u0026nbsp;However, the report of some women not being referred due to a lack of resources places the mother at high risk of preterm labour and preeclampsia [76,77] and reveals the gap in services offered at the PHC level. PHC facilities must be strengthened with essential resources, including personnel and equipment, and informed by women’s and HCWs’ needs to deliver quality care and reduce maternal and perinatal outcomes. Further research and programs are needed to strengthen the health system and ensure quality ANC, as well as to improve coverage of evidence-based ANC practices and people-centred outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvidence shows that women's, their families’, and communities’ perspectives on the quality of ANC services influence health-seeking behaviour, essential to improving demand and access to quality maternal and newborn services and providing people-centred ANC [9,19,78–83]. Our study evaluated ANC satisfaction across three domains: quality of ANC service delivery, adequacy of PHC resources, and interpersonal aspects of care. The services provided in our study were highly satisfactory due to their comprehensiveness. While most women were satisfied with the availability of incentives and the friendly, compassionate, and respectful attitudes of HCWs in Anambra [29], community members, especially those in Jigawa and Kebbi, were dissatisfied with HCWs' attitudes and the long waiting times during ANC services. Studies in Nigeria have reported overall satisfaction with the quality of service [11,29,38,63] and unfavourable HCWs’ attitudes affecting ANC utilisation and encouraging home deliveries without SBA [11,38,63]. Waiting times have also persistently influenced the satisfaction and utilisation of ANC services in Nigeria [38,61–63] and other LMICs [84,85]. The long wait in our study was due to\u0026nbsp;a shortage of HCWs, which could lead to burnout and poor-quality care due to the disproportionate number of clients to staff [16,84,86–88].\u003c/p\u003e\n\u003cp\u003eSlightly more than half were satisfied with the quality of ANC service delivery, particularly the physical examination and counselling/health education, but not the diagnostic tools [89]. There are varied reports on the experience of quality ANC in Nigeria. While some studies report positive perceptions [29,38,90,91], others present negative perceptions of the quality of service received [65,92]. Women in their third trimester\u0026nbsp;were less likely to be satisfied with the services rendered. Also reported in Ethiopia [89], this finding indicates poor provider-client interaction, as a woman in her third trimester should have had several opportunities to establish a good relationship with HCWs and receive comprehensive care, resulting in higher satisfaction [84]. Also, women who felt the service was expensive were less satisfied, perhaps because of the displeasure of paying out of pocket, a factor also reported in other studies as contributing to low uptake and facility delivery [11,65,81,82]. This calls for a community-level health insurance scheme to enable women, particularly in rural and underserved areas, to access quality care [50]. As seen with the provision of quality ANC, place of residence was also significantly associated with service satisfaction, perhaps due to the availability of resources in these settings. Additionally, women who attended ANC services for personal reasons were satisfied with the services received during their ANC visits, consistent with findings across high-, middle-, and low-income countries [83,93]. This shows that women consider the quality of care received, as poor-quality ANC can lead to late or non-attendance [94].\u003c/p\u003e\n\u003cp\u003eRegarding the adequacy of PHC resources, less than half of our respondents were “very satisfied” with them, especially amenities and medical equipment, consistent with other studies in Nigeria [11,38,62,95,96]. Inadequate resources affect women with a positive attitude towards ANC and could result in non- or under-utilisation of services [81].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the interpersonal aspect of care, slightly more than half of the women were “very satisfied” with the communication (i.e., time spent explaining the child’s health status, honesty, and openness to patients), respect and preservation of dignity (i.e., respect for patients), and social and emotional support (i.e., friendly to patients, time devoted to patients, and compassion for patients) similar to the findings in Kenya [48]. Conversely, poor communication, lack of respect, and abuse led to low satisfaction in Zimbabwe [84] and other LMICs [86,97]. Nevertheless, there is a need for improvement, including reducing waiting times. Women with\u0026nbsp;a primary school education tend to be more satisfied with the interpersonal aspects of care. Pregnant women who have attained primary school education may lack adequate knowledge about what constitutes appropriate care experiences compared to those with secondary education or higher [84]. Additionally, across the three domains assessed, women who accessed ANC health information were more likely to be satisfied with the ANC service received. Awareness of ANC services has positively affected women’s satisfaction [76], whereas insufficient information has led to poor satisfaction levels [98].\u003c/p\u003e\n\u003cp\u003ePolicymakers, program implementers, and donors must invest in patient-centred care through HCWs' education and training, supportive supervision of service provision, on-the-job mentoring, and the implementation of a service delivery and consumer protection initiative, such as SERVICOM, across all public PHC facilities to obtain feedback from women accessing ANC services for continuous quality improvement. There is also a need to strengthen social accountability at the community level by engaging communities to identify barriers to ANC utilisation, co-design feasible and culturally appropriate solutions, implement and monitor them, and hold policymakers and program implementers accountable for quality public service.\u003c/p\u003e\n\u003cp\u003eOur findings both validate and extend the WHO quality of care framework in the Nigerian context. While our results align with the framework's “provision of care” and “experience of care” domains, they also reveal critical gaps. The study highlights deficiencies in clinical service delivery and women's satisfaction, particularly regarding essential ANC components, waiting times, and HCWs’ attitudes. Importantly, our research underscores the significant influence of socioeconomic factors, notably income levels and employment, on ANC provision and experience, elements not explicitly addressed in the current framework. This suggests a need to expand the WHO framework to more robustly incorporate economic considerations, such as service costs and women's financial status, which impact ANC access and satisfaction. Enhancing the framework with these socioeconomic dimensions could improve its applicability across diverse settings, similar to Nigeria. However, further research is needed to comprehensively assess how the framework might be expanded to address other contextual factors influencing ANC quality and experience across various settings.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eWe had limitations worth mentioning. First, our study settings were purposively selected, which could limit the generalisability of our findings. However, the number of PHCs assessed provided valuable insights into ANC practices, showcasing areas for improvement in the quality of ANC, its utilisation, and maternal health outcomes. Our use of exit interviews eliminates observation bias, allowing these women to respond regarding the provision and satisfaction of the care they received. Second, we did not survey women who did not visit the PHC facilities. Still, we compensated for this by including them in the qualitative interviews. We also did not assess information systems within the PHC services due to our data collection source [99]. An observation is needed to determine the functionality of health information systems in public PHC facilities.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe quality of ANC for pregnant women accessing ANC services in public PHC facilities is found to be suboptimal in our study. We identified that factors such as service costs and living in the facility\u0026apos;s location influence the provision of good-quality ANC. Although the overall satisfaction with the care received was high, there are clear areas for improvement, including diagnosis, adequacy of HCWs, facility conditions- consulting rooms and privacy, medical equipment and amenities, and interpersonal aspects of care. Our study strongly supports the need to assess the quality of ANC, from the provision and the experience of care, to identify areas for improvement and reduce maternal morbidity and mortality. We recommend investment in health systems strengthening, including recruiting and training HCWs on providing women-centred care and ANC interventions according to the recommended standards and guidelines, available and adequate resources, supportive supervision of practice, and engaging communities and families to reduce equity gaps, promote positive pregnancy experience, and improve the quality of care and maternal and newborn outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003eANC: Antenatal care\u003c/p\u003e\n\u003cp\u003eFGD: Focus group discussions\u003c/p\u003e\n\u003cp\u003eHCW: Health workers\u003c/p\u003e\n\u003cp\u003eIDI: In-depth interviews\u003c/p\u003e\n\u003cp\u003eIPD: Intestinal Parasite Drugs\u003c/p\u003e\n\u003cp\u003eIPTp: Intermittent preventive treatment in pregnancy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKIIs: Key Informant Interviews\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLGA: Local Government Areas\u003c/p\u003e\n\u003cp\u003eLMICs: Low-income and middle-income countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNHREC: National Health Research Ethics Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOptiCCS: Optimising Client-Centred Services\u003c/p\u003e\n\u003cp\u003ePMTCT: Prevention of mother-to-child transmission\u003c/p\u003e\n\u003cp\u003eSBA: Skilled Birth Attendants\u003c/p\u003e\n\u003cp\u003eSSA: sub-Saharan Africa\u003c/p\u003e\n\u003cp\u003eWDC: Ward Development Committee\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eWe obtained ethical approval for the study from the National Health Research Ethics Committee of Nigeria (NHREC), NHREC/01/01/2007-04/07/2023. The assessment was conducted in accordance with NHREC’s guidelines and regulations. In addition, we used a standard oral consent script approved by NHREC to secure consent from all individuals interviewed. The consent script outlined the participants' consent to participate in the study, their confidentiality, protection from harm, and permission to record the interview for analytical purposes.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe dataset generated and analysed during this study is included in this published article and available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was funded by BACKUP Health, a global program of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, commissioned by the German Federal Ministry for Economic Cooperation and Development based on a project piloted by GIZ BACKUP Health. The funders had no role in the conceptualisation, study design, data collection, analysis, interpretation, decision to publish or manuscript writing.\u003c/p\u003e\n\u003ch2\u003eAuthors’ contributions\u003c/h2\u003e\n\u003cp\u003eCOJ designed the mixed-method study, developed the data collection tools and the analysis plan, supported the qualitative interview coding, interpreted the survey and qualitative analysis, and drafted the manuscript. LU, CE, AD, ZH, and OU reviewed the data collection tools. LU reviewed the manuscript. FO supervised the data collection and coded the qualitative interviews. Abduljaleel Adejumo conducted the survey analysis. Abdulazeez Abdulganiyu coded the qualitative interviews. EE reviewed the analysis and the manuscript. All authors read and approved the final manuscript for submission and agreed to be accountable for their contributions, ensuring that all questions regarding the accuracy or integrity of the work, even those unrelated to them, are investigated, resolved, and documented in the literature.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe appreciate the leadership of NPHCDA, the Department of Community Health Services, and the leaders and program managers of the Anambra, Jigawa, and Kebbi Primary Health Care Development Agency for their support during the study. We also recognise the support of the ANC HCWs from the 150 PHCs and the community members at the study sites. Additionally, we thank Rachael Olorupo, our state-based coordinators, and data collectors for facilitating the data collection across the sites.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. 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BMC Pregnancy Childbirth. 2024 Jan 2;24(1):20. \u003c/li\u003e\n\u003cli\u003eGong E, Dula J, Alberto C, de Albuquerque A, Steenland M, Fernandes Q, et al. Client experiences with antenatal care waiting times in southern Mozambique. BMC Health Serv Res. 2019 Dec 1;19(1):538. \u003c/li\u003e\n\u003cli\u003eMannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Global Health. 2015 Dec 15;11(1):36. \u003c/li\u003e\n\u003cli\u003eSumankuuro J, Crockett J, Wang S. The use of antenatal care in two rural districts of Upper West Region, Ghana. PLoS One. 2017 Sep 28;12(9):e0185537. \u003c/li\u003e\n\u003cli\u003eAkintola O, Hlengwa WM, Dageid W. Perceived stress and burnout among volunteer caregivers working in AIDS care in South Africa. J Adv Nurs. 2013 Dec 19;69(12):2738\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eEmiru AA, Alene G, Debelew GT. Women\u0026rsquo;s satisfaction with the quality of antenatal care services rendered at public health facilities in Northwest Ethiopia: the application of partial proportional odds model. BMJ Open. 2020 Sep 17;10(9):e037085. \u003c/li\u003e\n\u003cli\u003eTitilayo O, Oyewole O, Chidera A, Omosuzi M. Perception and level of satisfaction with the quality of antenatal care services among pregnant women attending antenatal clinic at plateau state specialist hospital, Jos, Nigeria. Afr Health Sci. 2023 Sep;23(3). \u003c/li\u003e\n\u003cli\u003eSayyadi BM, Gajida AU, Garba R, Ibrahim UM. Assessment of maternal health services: a comparative study of urban and rural primary health facilities in Kano State, Northwest Nigeria. Pan Afr Med J. 2021;38:320. \u003c/li\u003e\n\u003cli\u003eAjibola I, Israel OK, Akande RO. Access, Perceived Quality and Uptake of Antenatal Services in Urban Communities of Osun State, Southwest Nigeria. Afr J Reprod Health. 2022;26(12):78\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003evan Pelt S, van der Pijl M, A.C. Ruiter R, Ndaki PM, Kilimba R, Shields-Zeeman L, et al. Pregnant women\u0026rsquo;s perceptions of antenatal care and utilisation of digital health tools in Magu District, Tanzania: a qualitative study. Sex Reprod Health Matters. 2023 Dec 31;31(1). \u003c/li\u003e\n\u003cli\u003eGross K, Alba S, Glass TR, Schellenberg JA, Obrist B. Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania. BMC Pregnancy Childbirth. 2012 Dec 21;12(1):16. \u003c/li\u003e\n\u003cli\u003eEkenna A, Itanyi IU, Nwokoro U, Hirschhorn LR, Uzochukwu B. How ready is the system to deliver primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria. Health Policy Plan. 2020 Nov 1;35(Supplement_1):i97\u0026ndash;106. \u003c/li\u003e\n\u003cli\u003eAghaji A, Burchett HED, Oguego N, Hameed S, Gilbert C. Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems. BMC Health Serv Res. 2021 Dec 20;21(1):1360. \u003c/li\u003e\n\u003cli\u003eAfulani PA, Phillips B, Aborigo RA, Moyer CA. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. Lancet Glob Health. 2019 Jan;7(1):e96\u0026ndash;109. \u003c/li\u003e\n\u003cli\u003eAlemayehu A. Quality of Antenatal Care Service in Public Health Facilities of Chencha District, Gamo Gofa Zone, Southern Ethiopia. Women\u0026rsquo;s Health. 2017 Feb 21;4(3). \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. QUALITY OF CARE FOR MATERNAL AND NEWBORN HEALTH: A MONITORING FRAMEWORK FOR NETWORK COUNTRIES. 2019 Feb. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antenatal Care, Quality of Care, Provision of care, Experience of care, People-centred ANC, Access, Utilisation, Satisfaction, Pregnant women, Healthcare workers","lastPublishedDoi":"10.21203/rs.3.rs-8701959/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8701959/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuality antenatal care (ANC) is essential for improved maternal and newborn health outcomes. Yet, providing quality ANC services remains challenging in Nigeria, with suboptimal ANC coverage and the highest global maternal deaths. Using the WHO quality of care framework, we assessed the provision and experience of quality ANC services in public primary healthcare (PHC) facilities in Nigeria and the associated determinants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis convergent mixed-methods study was conducted in Anambra, Jigawa, and Kebbi states. We used a semi-structured questionnaire to conduct exit interviews with 1200 randomly sampled pregnant women accessing ANC services across 150 public PHC facilities in these states. Using semi-structured interview guides, we conducted 15 key informant interviews, 21 in-depth interviews, and 18 focus group discussions with purposively selected ANC healthcare workers (HCWs) and community members across the states. Quantitative data were analysed using descriptive statistics and logistic regression at p\u0026lt;0.05, and qualitative data were analysed thematically and triangulated with quantitative findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly 8.2% of participants received the recommended minimum quality of ANC services. Blood pressure measurement (76.5%) and blood testing (63.3%) were the most provided services, while tetanus vaccination (38.1%) and intestinal parasite drugs (14.0%) were the least. Satisfaction scores were 48.8-58.8% for service delivery, 46-48.8% for PHC resources adequacy, and 48.4-58.6% for interpersonal aspects of care. Free ANC services (aOR = 2.70; 95% CI: 1.5, 5.0), perceived expensive service (aOR = 3.76; 95% CI: 1.6, 8.5), urban residence (aOR = 1.72; 95% CI: 1.0, 3.0), attending ANC service due to personal choice (aOR = 1.87, 95% CI: 1.0, 3.5), accessible ANC information (aOR = 6.55, 95% CI: 1.8, 23.8; aOR = 5.95, 95% CI: 2.1, 16.8; and aOR = 8.98, 95% CI = 2.3, 33.2), and attaining primary school education (aOR = 3.18, 95% CI = 1.3, 9.9) were significantly associated with quality ANC, with long waiting times and insufficient HCWs and resources cited as major challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStrengthening health systems, including recruiting and training HCWs, ensuring adequate resources, providing supportive supervision, and engaging communities, are essential to improving ANC quality. The WHO framework should also include socioeconomic factors influencing ANC provision and satisfaction.\u003c/p\u003e","manuscriptTitle":"Provision and experience of quality antenatal care services in public primary health care facilities in Nigeria: a mixed methods study using the WHO Quality of Care framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 06:33:39","doi":"10.21203/rs.3.rs-8701959/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"299930174571193339214248381755686790403","date":"2026-03-04T14:50:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289733909560360809533778684219373056199","date":"2026-03-04T14:26:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116608278138823820967931958877137570505","date":"2026-03-03T15:26:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-03T12:41:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-02T13:22:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-28T11:52:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-28T11:49:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-01-26T15:31:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3378b995-10c7-4846-92ef-23b8bbc0e52e","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T06:33:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 06:33:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8701959","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8701959","identity":"rs-8701959","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}