CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Antenatal care can be defined as the care provided by skilled healthcare professionals to
pregnant women and adolescent girls to ensure the best health conditions for both mother and
baby during pregnancy (WHO, 2016). The woman and her baby are monitored on a regular
basis throughout the pregnancy period which involves routine regular examinations and various
medical investigative tests (Onwurah et al., 2015; Jibril, 2017; Ogunba and Abiodun, 2017).

Antenatal care can help women prepare for delivery and understand warning signs during
pregnancy and childbirth. ANC services can include immunization against tetanus, treatment of
hypertension which can lead to eclampsia, HIV testing and medications against its spread from
mother to child in positive cases, provision of micronutrient supplementation and in regions
where malaria is prevalent, insecticide-treated mosquito nets and medications can also be
provided (Kerber et al., 2007; UNICEF DATA, 2019).

Antenatal care has been considered an important factor in maternal and infant well-being
(Onasoga et al., 2012; Adewoye et al., 2013; Onwurah et al., 2015; Ali et al., 2018; Onyeajam et
al., 2018). The risks associated with childbearing in the case of the women; survival, growth and
development in the case of infants and children make women of reproductive age group and
children the most vulnerable and “special risk” members of the society and at the same time,
they also constitute a large proportion of the populace[CITATION Placeholder1 \l 2057 ].
Onasoga et al. (2012) reported that with maternal risk held constant, low birth weight, and
infant mortality were 1.5-5 times higher with late and less frequent antenatal care than with
early and frequent care. This supports the notion that improving the health of pregnant
women and new mothers is a critical step in reducing child mortality [ CITATION Ogu17 \l
2057 ].

The launching of the Sustainable Development Goals (SDGs) in 2015 saw the United Nations
Member States extend the global commitments of the Millennium Development Goals, one of
which is to reduce global Maternal Mortality Ratio (MMR) to less than 70 by 2030[ CITATION
Wor19 \l 2057 ]. MMR refers to maternal deaths per 100,000 live births. Reports indicated that
Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the
estimated global maternal deaths in 2017 with sub-Saharan Africa alone accounting for roughly
66% (196 000), while Southern Asia accounted for nearly 20% (58 000). South-Eastern Asia, in
addition, accounted for over 5% of global maternal deaths (16 000) (WHO, 2019). Reports
reveal that the mortality ratio in Nigeria is about 800 - 1,500 per 100,000 live births with

1
marked variation between the six geopolitical zones, 165 being recorded in the South-West
compared with 1,549 in the North-East and between urban and rural areas (Onasoga et al.,
2012; Jibril, 2017).

The qualitative comparative research study conducted by Pell et al. (2013) with outlined survey
results show that Antenatal contact schedule standards are usually not adhered, as most
pregnant women register in their first trimesters and do not move to keep other scheduled
appointments. The higher utilization of modern maternal health services in the developed
regions of the world has been reported to be the reason for very low maternal and infant
morbidity and mortality figures compared to those of the developing regions [ CITATION Jib17 \l
2057 ]. Records show that in more developed countries, maternal death is 1 in 3600 deaths, 1
in 90 deaths for less developed countries excluding china which records 1 in 120 deaths, 1 in 31
deaths in sub-Saharan Africa and in Nigeria, the ratio is 1 in 23 deaths (Fagbamigbe et al.,
2013).

Regrettably, ANC utilization rate in Nigeria is quite low, with roughly 61% of pregnant women
visited a skilled health provider at least once during their pregnancy (Onasoga et al., 2012;
Onyeajam et al., 2018). This is low compared with the documented average of 79% for all
lower-middle income countries (Onyeajam et al., 2018). According to Federal Ministry of Health
(2005), proper utilization of ANC services will prevent some of the risks associated with
pregnancy and childbirth. Identifying the factors causing poor utilization of antenatal care
services will boost ANC utilization which will help in reducing the morality rate.

Current guidelines developed in 2016 by the World Health Organization state that standard
Antenatal schedule of 8 visits beginning at the 12 th week and spread across the 20 th, 26th, 30th,
34th , 36th, 38th and 40th week of cyesis should deliver comprehensive and integrated
investigative and also clinical strategies geared to address nutrition, health education on the
prevention of diseases during pregnancy, fetal and maternal assessment, management of
physiologic pregnancy ill-health symptoms and finally the inclusion of continuous quality
improvement activities that increase Antenatal care uptake (WHO, 2018).

Since poor ANC is closely related to undesirable pregnancy consequences, understanding the
factors influencing proper and prompt utilization of ANC will help influence decisions by health
policy makers. Several factors have been documented to inhibit ANC utilization among
pregnant women. These factors include socio-economic, lack of knowledge about available
services, and reproductive characteristics, women’s autonomy, husband attitude and support,
family income, distance, accessibility and availability, cultural beliefs, limited availability of
health services (Fagbamigbe and Idemudia, 2015; Abimbola et al., 2016; Ogunba and Abiodun,
2017; Oluwamotemi et al., 2020).

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Women knowledge is regarded as one of the major drivers towards awareness of their right to
health and striving to seek proper health services (Jibril, 2017). For instance, the study carried
out by Gharoro and Igbafe (2000) revealed that ignorance was the underlying factor in late
commencement of ANC in 41% of the pregnant women accessing care in a Nigerian Teaching
Hospital while only 25% indicated financial constraints.

1.2 STATEMENT OF THE PROBLEM

A study reported that with maternal risk held constant, low birth weight, and infant
mortality were 1.5-5 times higher with late and less frequent antenatal care than with early and
frequent care (Onasoga et al., 2012).

Government or public health facilities are the principal source of care for the Nigerian
population, particularly in rural areas. Adewoye et al. (2013) observed that over three-quarters
of the respondents that attended antenatal care when they had their last pregnancy did so in a
public health facility. This is also supported by Abimbola et al. (2016) where their findings
showed that about two-thirds utilized a public health facility in the community for ANC services.
This was attributed to a subdized rate of antenatal care services in public health facilities
(Adewoye et al., 2013 ; Abimbola et al., 2016)

Despite the fact that the cost of services are cheaper in government facilities than private ones,
ANC services among other health services are still being under utilized.

1.3 AIM AND OBJECTIVES OF THE STUDY

This study aims to explore the knowledge of pregnant women on Antenatal Care Services and
their perspectives on reasons affecting attendance across Government healthcare facilities in
Lagos State, South-West Nigeria.

The Research objectives will include:

1. To explore the perceptions and understanding of pregnant women on the current

standards of Antenatal care contact schedule as recommended by the WHO and its
benefits.
2. To determine the attitudes of pregnant women toward antenatal care visits.
3. To determine the frequency and timing of antenatal care visits of pregnant women.
4. To explore reasons associated with poor adherence to the attendance of Antenatal
care visits among pregnant women based on WHO standards.

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 5. To engage pregnant women in conferring solution strategies which will aid in
promoting their adherence to the WHO standard recommendations for ANC
attendance, thus promoting collaborative action, inclusivity, and community
participation.

1.4 CONTEXT AND RATIONALE

Data from Sub-Saharan Africa with context to Nigeria show that 1 in every 13 Nigerian woman
is at risk of dying during pregnancy as compared to ratios of 1 in every 31 in other regions
across Sub-Saharan Africa (APHRC, 2017). Statistics also reveal that deaths from pregnancy and
delivery related complications is most prevalent in low- and middle-income countries with
303,000 deaths of women and adolescent girls recorded in 2015 and 2.6m stillbirths with
malaria, hypertension and poorly managed infections during antenatal accounting for 60% of
the stillbirths within the same year (WHO, 2018).

1.5 SIGNIFICANCE OF STUDY

Antenatal care utilization rate in Nigeria is quite low, and this can be attributed to a number of
factors. Pregnant women are the main beneficiaries of antenatal care Servies. This study aims
to understand how much pregnant women know about antenatal care services and the factors
affecting the low utilization of these antenatal care services.

This study will aid health care policy makers in developing localized strategies for effective
utilization of antenatal care services, which will help to reduce maternal and neonatal
morbidity and mortality rates.

1.6 SCOPE OF STUDY

This study will be a qualitative research with the target population being pregnant women over
the age of 18 years, of any gestation age, either primiparous or multiparous and registered for
Antenatal care attendance at the proposed research sites.

The Isolo General Hospital, the Maternal and Child Center in Amumo Odofin Local Government
Area and the Randle General Hospital all located in Lagos State, Nigeria are the three proposed
sites where the study will be conducted.

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Exclusion criteria includes, pregnant women below the age of 18 years, those who have sight,
speech and auditory disabilities, pregnant women with health challenges regardless of
gestational age and those set to be admitted for normal vertex or assisted delivery.

CHAPTER TWO
LITERATURE REVIEW

2.1 OVERVIEW
Antenatal Care Services (ANC) has proven to be an effective approach towards improving the
health of pregnant women and child and increasing the survival rate of both during pregnancy
and childbirth (Rwabilimbo et al., 2020).

Regrettably, despite the benefits obtained from the use of ANC services in terms of reducing
maternal and neonatal mortality, ANC services is still being underutilized in Nigeria
(Oluwamotemi et al., 2020). Nigeria and India had the highest estimated numbers of maternal
deaths, accounting for approximately one third (35%) of estimated global maternal deaths in
2017 (World Health Organization, 2019).

2.2 ANTENATAL CARE SERVICES IN GOVERNMENT HEALTHCARE

FACILITIES
Government or public healthcare facility is the principal source of care for the Nigerian
population. This is supported by Adewoye et al. (2013); Abimbola et al. (2016) and Iyaniwura
and Yussuf (2009) where more than half of the women that attended antenatal care when they
had their last pregnancy did so in a public health facility. Despite the fact that the cost of
services are cheaper in government facilities than private ones, ANC services among other
health services are still being underutilized.

2.3 FACTORS AFFECTING THE UTILIZATION OF ANTENATAL CARE

SERVICES
Regular attendance at ANC facilities can prevent some of the complications associated with
pregnancy and childbirth. However, proper antenatal care utilization will be accomplished only
if the factors causing poor utilization of antenatal care services are known (Onasoga et al.,
2012).

5
The ability to utilize ANC services in developing countries is affected by a number of factors
(Fagbamigbe et al., 2013; Ali et al., 2018). In investigating the factors affecting ANC utilization,
Andersen’s behavioral model of health service utilization (Andersen 1995; Andersen and
Newman 2005) can aid in conceptualizing these factors (figure 2.1). The model was developed
in 1968 by the US medical sociologist and health services researcher Ronald M. Andersen. The
Andersen framework is a health behaviour model that aids in the investigation of key
contributing factors affecting health services utilisation and is one of the most widely
acknowledged models in health care utilization (Babitsch et al., 2012; Srakar et al., 2016; Ali et
al., 2018).

Figure 2.1 Andersen’s Behavioral Model of Health Services Use

Source: (Andersen, 1995)

The model has been adopted by a number of researchers to study the factors associated with
the utilization of ANC services (Amin et al., 2010; Ali et al., 2018; Mbugua and MacQuarrie,
2018; Okonofua et al., 2018; Okedo-Alex et al., 2019; Neupane et al., 2020; Rwabilimbo et al.,
2020; Tolera et al., 2020).

According to the Andersen’s behavioral model, the factors affecting health services utilisation
are categorized into three broad areas namely predisposing factors, enabling factors and need
factors (Andersen, 1995; Andersen and Newman, 2005).

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Predisposing factors refer to individual traits that exist prior to the pregnancy and affect the
predisposition towards health care use. Enabling factors refer to the conditions that permit
individuals to obtain health services refer to conditions that make ANC available to pregnant
women. The need factors include perceived illness or the odds of getting into a life-threatening
situation.

With respect to ANC, predisposing factors include demographic characteristics such as age, sex,
marital status. Enabling factors refer to conditions that facilitate the accessibility of ANC. These
include family income, availability of health insurance coverage. The need factors include
pregnancy-related illnesses such as severe headache, high fever. The modified model for ANC
utilization is shown in figure 2.2.

7
Figure 2.2 The conceptual model for ANC service utilization adapted from Anderson’s
Behavioral Model of Health Services Use

Some of the important factors affecting utilization of antenatal care services are discussed
below in details.

Education
Abimbola et al. (2016) reported that respondents with higher educational exposure utilized
antenatal care services more than those with lower or no education. This finding is consistent
with the results of several studies in which strong relationship has been demonstrated between
the level of education and utilization of maternal health care services (Mekonnen and
Mekonnen, 2003; Babalola and Fatusi, 2009; Iyaniwura and Yussuf, 2009; Dairo and Owoyokun,
2010; Onasoga et al., 2012; Ogunba and Abiodun, 2017; Neupane et al., 2020). This is not
surprising as educated women are often likely to be more aware of health issues and the
available health care services that in turn makes them utilize the services more efficiently than
their non-educated counterparts do (Dairo and Owoyokun, 2010; Onasoga et al., 2012;
Abimbola et al., 2016; Nwankwo and Ezenwaka, 2020).

This is consistent with Eijk et al. (2006) in their study in rural western Kenya where women with
over 8 years of education attended ANC more than those with lesser years of education did.
Saseendran et al. (2007) in a study carried out in India also found women with a secondary
school education or more were more likely to attend ANC than women with primary school
education or less. Jat et al. (2011) and Ali and Chauhan (2020) also reported that mother’s
education is one of the strongest individual level factors influencing the use of ANC services in
India.

However, Dairo and Owoyokun (2010) in their study carried out in Ibadan, Nigeria observed
that level of education had no influence on the utilization of ANC services. They reported it
could possibly be due to the fact the level of awareness on the significance and benefits of
antenatal care cut across the different levels of education in that community.

Marital status
Results from various studies have found mixed evidence of an association between marital
status and utilization of ANC services. For instance, Onasoga, et al., 2012 discovered that there
was a positive correlation between marital status and the utilization of ANC services. In their
study, the married women utilized ANC services more than the single mothers did while the
divorced mothers utilized the services the least. Likewise, Dairo and Owoyokun (2010) observed
married women were more likely to attend ANC clinic compared to women who were single,

8
separated or divorced than the single mothers. In their study, the single mothers reported that
they were mostly left out of the decision-making on matters that affects their health.

Source of information
Fagbamigbe et al. (2013) observed that almost half of the respondents obtained information
about ANC services from health workers while others were informed through relatives, news
media and friends. Adewoye et al. (2013) in their study also observed that majority of those
who attended ANC were advised by their mothers while the rest were advised by their
husbands and friends.

Onasoga et al. (2012) also reported that hospital was the first source of information for close to
50% of the respondents. Schools, friends and other means of information were also reported as
major sources of information. Iyaniwura and Yussuf (2009) also reported friends, relations and
health workers as vital sources of information.

Studies carried out in Nepal (Neupane et al., 2020) and India (Ali and Chauhan, 2020) have
shown that women having exposure to radio, TV, and newspaper were likely to attend ANC
more frequently than those without access to these mass media outlets.

Knowledge of Antenatal Care Services

Studies have revealed that sufficient knowledge of the benefits of ANC and of the complications
associated with pregnancy plays an important role in the utilization of ANC services (Ali et al.,
2018). Onasoga, et al. (2012) observed that there was significant association between
knowledge of respondents and their attendance at ANC. They observed that over 80% of the
respondents are/were aware of the services rendered at antenatal clinic.

Adewoye et al. (2013) in their study in North Central Nigeria also observed that close to 90% of
the respondents were conversant with antenatal care. They attributed this to the high literacy
status of the respondents and high level of awareness of antenatal care. They also reported
that over two-thirds of them had good knowledge of the activities carried out under antenatal
care services. This is similar to Abimbola et al. (2016) who also observed that majority the
respondents were aware of antenatal services though less than half of them had very sound
knowledge of the activities carried out during the ANC services. Studies in Southwest Nigeria
(Iyaniwura and Yussuf, 2009; Fagbamigbe et al., 2013) also reported that almost 90% of
respondents were aware of antenatal facilities in the community.

9
Having a sound knowledge of ANC services is very important for women. This is evident from
the study of Oluwamotemi et al. (2020) where they discovered that over half of the women did
not know ANC should commence immediately following the confirmation of a pregnancy and
more than 60% of them were ignorant of the fact that ANC helps in timely discovery of
complications in pregnancy. This was ascribed to factors like the level of education of mothers,
the regularity of ANC visits, the time of ANC commencement and the source of information
about ANC and the knowledge circulated among mothers (Oluwamotemi, et al., 2020).

High socio-economic status

Abimbola et al. (2016) observed that high socio-economic status and utilization of antenatal
and delivery services are positively correlated. This is consistent with other studies in Nigeria
(Babalola and Fatusi, 2009; Iyaniwura and Yussuf, 2009; Nwankwo and Ezenwaka, 2020). It is
also in line with studies in Kenya (Eijk et al., 2006), Tanzania (Mrisho et al., 2009; Rwabilimbo et
al., 2020) and some parts of Asia (Amin et al., 2010; Jat et al., 2011).

Babalola and Fatusi (2009) buttressed this fact by reporting that women with higher socio-
economic status were likely to utilize ANC services almost six times more than those with very
low socio-economic status.

Financial Constraints
Financial Constraint has been reported as a major hindrance towards accessing the ANC in
Nigeria (Fagbamigbe and Idemudia, 2015; Abimbola et al., 2016; Ekpenyong et al., 2019;
Nwankwo and Ezenwaka, 2020). Poverty has been reported by the United Nations as a major
barrier to ANC utilization across developing countries (Fagbamigbe and Idemudia, 2015).
Ekpenyong et al. (2019) acknowledged financial necessity as a compelling factor for poor
decision making concerning seeking care in health facilities. The study by Ogundairo and Jegede
(2016) revealed that majority of the women took herbs during pregnancy which they linked to
lack of financial capability to seek healthcare services.

Parity
Mekonnen and Mekonnen (2003), in their study in Ethiopia discovered that women with lesser
children tend to use ANC services more than those with higher number of children which
implied that the higher the parity, the less frequent the use of ANC services. This is also similar
to the study conducted in Kenya (Van Eijk et al., 2006), India (Ali and Chauhan, 2020). The

10
anxiety of first pregnancy can make women more cautious and willing to seek medical care to
avoid complications that may lead to women of higher parity relying on the experience and
knowledge from previous pregnancies and not attending ANC as expected (Ali and Chauhan,
2020).

However, Abimbola et al. (2016) in their study in North-Central Nigeria established that parity
had a positive correlation with utilization of ANC services that implied that women with higher
number of children used ANC services more frequently than those with lower number of
children.

Surprisingly, some studies have reported that that parity is not a defining factor in the use of
ANC services (Babalola and Fatusi, 2009; Dairo and Owoyokun, 2010; Onasoga, et al., 2012).

Distance
Reports have revealed that the negative correlation between long distances and attendance of
ANC (Titaley et al., 2010; Onasoga et al., 2012; Ekpenyong et al., 2019; Nwankwo and
Ezenwaka, 2020). Trekking long distances or lack of adequate transport facilities can be tedious
for pregnant women. (Fagbamigbe and Idemudia, 2015 discovered that nearly half of those
who did not go for ANC services complained of the far location of the facilities. They attributed
that the problem of cost of transportation to lower educational level, poorer economic status,
Northern zones, ethnicity and employment status of the respondents. This finding was
resonated in the study by Ekpenyong et al. (2019) on the premise that many of the women did
not have readily available transportation to visit healthcare facilities hence have to depend on
their husbands for support. Griffiths and Stephenson (2001) concluded that women tend to
attend ANC services more when the service is within reasonable distance of the women’s place
of residence.

Communication barrier
Though communication barrier is not a common factor reported as affecting ANC services, it is
still an aspect to look into in a multilingual society like Nigeria. Ogundairo and Jegede (2016)
studied communication barrier as a factor affecting utilization of ANC services. They discovered
that women from a culturally and linguistically diverse (CALD) background could discourage
them from utilizing ANC and other health care services due to language barrier.

11
Age
Iyaniwura and Yussuf (2009) in their study in South Western, Nigeria reported that a higher
proportion of the women who were less than 20 years did not use ANC facilities compared to
women in the older age groups. This is similar to the study of Dairo and Owoyokun (2010) and
Oluwamotemi et al. (2020), both in South Western, Nigeria, where they observed that women
who were 25 years or more were more likely to attend ANC clinic more than women who were
less than 25 years. The authors suggested that this might be due to the older women being
more knowledgeable and more aware of the benefits thereby placing more importance on
modern health care (Dairo and Owoyokun, 2010). It could be reasoned that young women may
lack social support and unwilling to utilize maternity health services (Iyaniwura and Yussuf,
2009). They may also need financial support and may require husband’s permission before
seeking health care (Ekpenyong, et al., 2019).

In contrast, Studies in India (Jat et al., 2011; Ali and Chauhan, 2020) indicated that pregnant
women who were younger have a tendency to use antenatal care more which implied that with
the increase in age, the utilization of ANC services goes on decreasing. This is also consistent
with the studies in Tanzania (Rwabilimbo, et al., 2020).

It has also been reported in some studies that age of the women is not a significant barrier to
utilization of antenatal services (Babalola and Fatusi, 2009; Abimbola et al., 2016). Babalola and
Fatusi (2009) explained that the use of ANC services initially increases up to a level and
decreases thereafter.

Employment Status and Occupation

Abimbola et al. (2016) reported that women who were gainfully employed utilized ANC services
more than those who were not employed.

Dairo and Owoyokun (2010) discovered that the type of occupation of husbands of respondents
had a significant relationship with the level of attendance of ANC services. In their study,
respondents whose husbands were professionals tended to utilize ANC services more than
those whose husbands were skilled and unskilled.

Quality of Service
In the study of Abimbola et al. (2016), women that attended ANC reported to have obtained
evidence-based services like counseling, malaria prevention treatments, health education and

12
other pregnancy related health services that may have increased their utilization of ANC
services.

Fagbamigbe and Idemudia (2015) in their study discovered that many did not attend ANC clinic
because of lack skilled health workers, poor attitudes of the workers, lack of trust with their
personal information and inadequate good drugs for them. They concluded that poor attitude
and unprofessional conduct of health workers made up over a quarter of the reasons why
pregnant women did not utilize the ANC services. This is also similar to Ogundairo and Jegede
(2016) where their findings reveal that most women preferred private health care centres
because of no preferential treatment based on culture or ethnic group usually found in public
healthcare centres.

Ekpenyong et al. (2019) and Oluwamotemi et al. (2020) also reported that stress in the health
care centres, long waiting time and poor attitude of health care workers discouraged pregnant
women from utilizing ANC services.

Culture and Influence

The patriarchal structure of the society like Nigeria has an effect on the ability of women to
utilize ANC services as some may require husband’s permission and social support (Ogundairo
and Jegede, 2016; Nwankwo and Ezenwaka, 2020). Iyaniwura and Yussuf (2009) who observed
that almost over 90% of the respondents still sought their husband’s permission before seeking
health care support this claim.

This is in contrast with the study in Kenya (Van Eijk et al., 2006) where most women made
independent decision to attend ANC. Likewise, Dairo and Owoyokun (2010) reported that
respondents who make decisions alone concerning their health or decide together with their
husbands were more likely to utilize ANC more than those whose decisions are made solely by
their husbands or someone else.

2.4 RESEARCH APPROACHES AND METHODOLOGIES

In the studies reviewed in this work, various research approaches have been employed in the
study of ANC utilization in Nigeria and other parts of the world. Examples of such studies that
employed the use of quantitative approach solely are Van Eijk et al., (2006), Iyaniwura and
Yussuf (2009), Adewoye et al. (2013), Ogunba and Abiodun (2017), Onyeajam et al. (2018).
Some that employed the use of qualitative approach exclusively are Ogundairo and Jegede
(2016), Mrisho et al., (2009), Titaley et al. (2010) and Muwanguzi (2018). Certain studies that

13
mixed both quantitative and qualitative approaches are Abimbola et al. (2016), Wolderufael
(2018), Ekpenyong, Bond, and Matheson (2019) and Oluwamotemi et al. (2020).

Quantitative research typically explores specific and clearly defined questions that serve as a
departure point of the research whereas qualitative research aims to explore examine the
relationship, which gathers and puts the lived experiences and reality of the participants in the
centre and as a starting point [CITATION DMu18 \l 2057 ]. Qualitative research are employed in
studying the quality of healthcare and to discover barriers that may be eluded through
quantitative methods (Kim et al., 2019). In addition, qualitative analysis is advantageous in that
it enables the understanding of social factors or personal experiences (Kim et al., 2019).
Qualitative methodologies are invaluable because they lead to discovery of new concepts and
allow easy data management but lack the ability to generalize study results to the entire
population (Atieno, 2009). Qualitative data collection methods are observation, interview, focus
group discussion, rapid assessment procedure (RAP), free listing, ranking and life history
(biography).

2.4.1 FOCUS GROUP DISCUSSION

A focus group is a coordinated arrangement discussion between a group of 6-8 people on a
specific event in which they have a shared experience (Srivastava and Thomson, 2009). Focus
group discussions allow you to explore how a group thinks about an issue, the range of opinions
and ideas, and the inconsistencies and variations that exist in a particular community in terms
of beliefs and their experiences and practices.

Focus groups are a social method of obtaining research data through informal group
discussions on a specific topic. Compared to other methods such as individual interviews and
surveys, the interactive and synchronous group discussion aspect of focus groups allows
participants to discuss, agree, or dissent with each other’s ideas and to elaborate the opinions
they have already mentioned (Nili, Tate and Johnstone, 2017).

Some of the advantages a focus group has as pointed out by Kielmann, K., Cataldo, F. and
Seeley, J. (2012) are :

i. The group is organised by the researcher. Hence, it is composed of individuals who

share a number of characteristics (e.g., age, sex, occupation, experience of a
particular condition).
ii. It may help in studying how people react and are influenced by others when in a
group. Group interactions are used to obtain information from group members in
relation to a clearly defined topic.

14
 iii. Since the members are of the same group, it may be an opportunity to relax and talk
freely by sharing intimate experiences.

Some limitations of focus groups as pointed out by Kielmann, K., Cataldo, F. and Seeley, J.
(2012) are:

i. It is not always easy to organize a group of people together, particularly if they are
not familiar with one another.
ii. The control in a focus group is less than in a one-on-one interview. It may be difficult
to observe and record reactions, gestures and interactions in the discussion
compared to a one-on-one interview.
iii. Focus group discussions are susceptible to interruptions and lack of flow. This might
be due to individuals coming in or leaving at some point. Discussion might lead to an
emotional situation which may be useful to study the group dynamics or lead to
disruption of flow.

2.4.2 QUALITATIVE DATA ANALYSIS

This process draws interpretations from the data. Qualitative Data can be analysed through

1. Content analysis
2. Narrative analysis
3. Discourse analysis
4. Grounded theory
5. Framework analysis

2.4.3 FRAMEWORK ANALYSIS

Framework analysis is a qualitative method that is aptly suited for applied policy research.
Framework analysis originated in an independent qualitative research unit in the Social and
Community Planning Research Institute situated in London, England. It was developed by two
qualitative researchers, Jane Ritchie and Liz Spencer in 1994 (Srivastava and Thomson, 2009).
Framework analysis is flexible such that it allows the data to be analysed either during the data
collection process or after (Srivastava and Thomson, 2009).

Framework analysis has been widely used in in healthcare studies (Srivastava and Thomson,
2009; Gale et al., 2013; Ward et al., 2013). Its distinct feature is that the data is summarized
into columns (codes) and rows (cases) providing a simplified structure, which aids in identifying
patterns easily (Gale et al., 2013). Some of the strengths of Framework analysis are enumerated
below:

15
 i. Framework analysis provides the researcher with a systematic structure that is visual
and transparent, enabling the development and maintenance of a clear audit trail from
the start of data analysis (Hackett and Strickland, 2018). This provides a concise
systematic analysis procedure, which reduces the complexity of a research (Gale et al.,
2013; Ward et al., 2013).
ii. Framework analysis is an iterative and repetitive process which ensures that the
researcher become more familiar with the data thereby leading to better grasp of the
thoughts and experiences of the study’s participants (Gale et al 2013).
iii. It can be performed using qualitative data analysis software (Gale et al 2013; Ward et al
2013). This is particularly valuable when the research is multidisciplinary and involves
large data set (Hackett and Strickland, 2018).
iv. Finally, it can be used without qualitative data analysis software (Hackett and Strickland,
2018). This can be of benefit in cases of limited funds especially if the research is not a
complex one. It also eliminates the need and stress of learning the software usage.

However, framework analysis is also faced with limitations, some of which are listed below:

i. The ambiguity of the terms can be sometimes confusing, which is typical of many
approaches to qualitative data analysis and this can be removed by having a good
understanding of the basic analytical steps (Hackett and Strickland, 2018). As with all
qualitative data analysis, it is time-consuming and resource-intensive (Gale et al., 2013).
ii. In addition, creating the theoretical framework, constructing the thematic charts and
summarising the data can be complicated, especially if there is any ambiguity in the
data. Parkinson et al (2016) concurred and stressed the importance of being mindful of
the aims of the research and the research questions throughout the analysis.
iii. Gale et al. (2013) emphasized that experience in qualitative analysis helps in successful
use of the framework approach. He also stressed the importance of spreadsheets skills
that are essential where special packages are not available.

Framework analysis is carried out in five stages:

i. Familiarization;
ii. Identifying a thematic framework;
iii. Indexing;
iv. Charting; and
v. Mapping and interpretation (Ritchie and Spencer, 1994 cited in Srivastava and
Thomson, 2009).

Familiarization: At this first stage, the researcher becomes engrossed and familiar with the
data. This is through listening to the audio tapes, studying the field or reading the transcripts.

16
Observation or field notes which makes him become aware of key ideas and recurrent themes
and make a note of them (Srivastava and Thomson, 2009; Green and Thorogood, 2010).

Identifying a thematic framework: the second stage, the researcher sees emerging themes or
topics in the data set. These emerging themes may be from known concepts or new ones,
however, the researcher must make sure the data dictate the themes and not from his own
prior perspective (Srivastava and Thomson, 2009). The salient concepts and themes that have
emerged from the data now forms the building block for a thematic framework that will aid in
filtering and classifying the data (Srivastava and Thomson, 2009)

Indexing: this involves using numerical or textual codes to identify specific piece of data
which correspond to different themes. Indexing can also adequately be done using numeric
systems (Ritchie and Spencer, 1994 cited in Srivastava and Thomson, 2009), and computer-
based software, which assists in analysing qualitative data (Srivastava and Thomson, 2009).

Charting: where indexed data is represented in themed charts and graphically shows data
arranged under ‘’headings and subheadings’’ (Srivastava and Thomson, 2009). Charts contain
mostly data that is summarized, as this gives the researcher a clearer view of the data ‘’across
cases and under themes’’ (Green and Thorogood, 2010).

Mapping and interpretation: this involves searching for patterns, associations, concepts and
explanations in the data. This final process aids in showing the relationships and associations
about the situation of focus, using tabular and diagrammatic methods (Green and Thorogood,
2010), thus providing the researcher, a basis for the interpretation of the data set (Srivastava
and Thomson, 2009).

17
 CHAPTER THREE
METHODOLOGY

3.1 RESEARCH DESIGN

A qualitative research design was chosen for this study to follow a holistic approach to explore
the knowledge of pregnant women about ANC and seeks to explain how they feel about
reasons affecting ANC utilization and why.

3.2 ETHICAL CONSIDERATION

Ethical approval will be sought from the University of Roehampton ethics committee. Ethics will
also be sought from the Lagos State research ethics board and permission sought from the
management of the general hospitals where the research will be conducted. Informed consent
forms will be administered to study participants detailing the purpose of the study, ensuring
confidentiality and the right to refuse participation or withdraw from study at any time. It will
also contain information on possible ethical issues such as delays, physical tiredness,
inconvenience, which will be curbed by ensuring timeliness, providing refreshment and short
breaks between discussions respectively. Informed consent forms will also adopt a local theme
with varied languages, if applicable with an interpreter made available which may require third
party approvals. The researcher will have a focus group guide while the study observer and
interpreter will be offered confidentiality documents. Study participants will also be distinctly
grouped with the consideration of heterogeneity in mind. Physical hard copies of documents,
audio tape, notes will be stored in a locked cabinet and electronic data will be secured with
passwords. The author will be in close contact with the health facilities administration before,
during and after data collection.

3.3 STUDY SETTING

The Isolo General Hospital, Maternal and Child Center, Amumo Odofin and the Randle General
Hospitals, located in Lagos State, Nigeria are the three proposed sites where study will be
conducted. They are appropriate sites because they are all secondary level government
hospitals, which provide subsidized healthcare services for ANC and delivery (Olusayo, 2016)
with health services provided by all cadres of healthcare professionals, including, doctors,
nurses, midwives, and laboratory scientists.

18
3.4 TARGET AND STUDY POPULATION
3.4.1 INCLUSION CRITERIA
Pregnant women over the age of 18 years, of any gestation age, primiparous, multiparous and
fully registered for Antenatal care attendance at the proposed research sites will be included in
this study.

3.4.2 EXCLUSION CRITERIA

Pregnant women below the age of 18 years, those who have sight, speech and auditory
disabilities, pregnant women with health challenges regardless of gestational age and those set
to be admitted for normal vertex or assisted delivery and those who did not give their consent
were not allowed to participate in the study.

3.5 SAMPLE SIZE DETERMINATION

In choosing the sample size, the principles of saturation and quality of information will be
employed while taking into cognizance the optimum sample size to adequately meet research
aims and objectives (Malterud et al., 2015). The study sample size of the proposed research will
be 12 study participants per research site, making 36 study participants in total.

3.6 SAMPLING AND RECRUITMENT OF PARTICIPANTS

Purposive sampling will be used to source potential study participants from the antenatal care
clinic of the research sites. Purposive sampling uses qualitative approaches with the intention
of mixing the participants of a target population, thus capturing the whole population (Barbour,
2001). It is the most appropriate sampling method for the proposed research study, as it hinges
on the epistemological paradigm of interpretivism (Wahyuni, 2012). Purposive sampling also
ensures rigour, as bias is avoided and will aid in ensuring study objectives and goals are met
(Easterby-Smith et al., 2012 cited in Laureate Education, 2018).
Recruitment scripts will be used to sensitize sourced participants, from which sample
participants will emerge and then led through the informed consent process, for the emergence
of study participants (Jacobsen, 2012).

3.7 EXPOSURES AND OUTCOMES

Outcomes variables typically show what is being measured and align with the aims and
objectives of the study (Vetter and Mascha, 2017). Primary outcome variable for the proposed
research includes, ‘’ poor knowledge’’, of WHO standards for ANC attendance, while secondary

19
outcomes variables may include, illiteracy, distance to the hospital, unavailability of social
infrastructures, bad roads, poor health-seeking behaviour, self-medication practices, poverty,
lack of support from spouse or family, lack of adequate number of healthcare personnel. The
primary and secondary outcomes variables are possible contributory factors to the reasons why
pregnant women do not adhere to ANC scheduled visits. The primary outcome will advance
health education and awareness activities, while secondary outcomes advance policy and
advocacy action, all aimed at improving quality of life and ensuring better health outcomes for
mother and child (Garg, 2016).

3.8 DATA COLLECTION

Focus group discussion (FGD) is the proposed qualitative data collection method and so chosen
because, it supports the interpretivist epistemological paradigm, where the researcher and the
researched become one (Wahyuni, 2012).

The FGD will be conducted with the aim of gathering information about the services offered in
ANC, perceptions about the reasons and importance of ANC, factors affecting ANC utilization,
and lastly, suggestions on how to improve ANC.

Data collection tools for focus group discussions include

i. A focus group discussion guide, which is a detailed worksheet, of the elements of the
focus group to ensure conformity for study replication purposes.
ii. Informed consent form to be administered to study participants.
iii. Socio-demographics form for study participants.
iv. Confidentiality documents to be signed by observer and interpreter.
v. A pretested audio recorder.

Focus groups discussions will be conducted in a conducive environment. A quiet and safe place
within the health facility premises will be identified for carrying out the focus group discussions.
The focus groups discussions will be conducted by the interviewer i.e. the researcher and an
observer, who will handle the aspect of audiotaping, observing salient expressional gestures
and taking notes.
The researcher will work with a FGD guide, which will contain 10 questions that were capable of
generating robust discussion among participants on the topic rather than yes or no responses.
Focus group discussions will be held in three groups of four participants each, with discussions
lasting for 1 hour inclusive of breaks to ease inconvenience.
During the group discussions, the interviewer will supplement the interview guide with follow-
up questions, if necessary to further the discussion, or explore the study participant’s

20
responses. Supplementary notes will be taken during the discussions to capture impressions
and observations.

3.9 DATA MANAGEMENT

At the end of each discussion, audio files from the recorder will be backed up on a personal
computer before deleting from the recording device. The audio data will be transcribed
manually and typed using a computer. The audio files and the typed transcripts will be secured
on a computer using passwords. They will also be stored on an external hard drive to prevent
loss of data. The hard copies of the transcripts, supplementary notes and external hard drive
will be stored in a secure cabinet and protected from anyone who was not part of the study.
The audio files and data documents will be deleted from the computer and from the external
hard drive upon completion of the Master’s thesis.

3.10 DATA ANALYSIS

Framework analysis is the proposed data analysis for this study. Unlike many of the qualitative
data analysis techniques, framework method is not allied with a specific discipline and
supported by philosophical opinions, which can influence the process of analysis (Gale et al.,
2013; Hackett and Strickland, 2018).
Study data will be analysed based on the following five steps of the framework approach:
i. Familiarization;
ii. Thematic analysis;
iii. Indexing ;
iv. Charting; and
v. Mapping and Interpretation.

21
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