Assessment of Antenatal Care Attendance and Determinants of Facility-Based Delivery Among Enrollees of the Kano State Contributory Healthcare Management Agency in northern Nigeria

In many parts of the world, the journey to motherhood is fraught with invisible hurdles. Before a child is born, a mother is expected to visit a clinic several times to check on her health and the baby's growth; this is known as antenatal care. These visits are not just check-ups but a critical safety net, allowing doctors to spot dangers early and prepare for a safe birth. When a woman gives birth in a hospital or clinic with a trained professional present, it is called a facility-based delivery. This practice is widely recognized as one of the most effective ways to prevent mothers and babies from dying during childbirth. However, in places like northern Nigeria, getting to these services is often difficult. Families may lack the money to pay for care, or the clinics may be too far away or poorly equipped. To solve this, governments sometimes create health insurance programs that cover these costs, hoping to remove the financial barrier and encourage more women to seek professional help.

Researchers in Kano State, a large and populous region in northern Nigeria, wanted to see if a specific local health insurance program was working as intended. This program, run by the Kano State Contributory Healthcare Management Agency, was designed to pay for maternal care so that women would not have to pay out of their own pockets. The team of researchers, led by scholars from local universities and hospitals, set out to understand the real-world experience of women enrolled in this scheme. They asked a simple but vital question: did the insurance actually lead to more women getting regular check-ups and giving birth in a medical facility? To find the answer, they traveled to twenty-four different health centers across the state, from small rural clinics to larger city hospitals, and spoke directly with over one thousand women who had recently given birth.

The researchers gathered their information by interviewing these women, asking about their education, where they lived, how many times they visited the doctor during pregnancy, and where they ultimately delivered their babies. They looked closely at whether the women had paid any money themselves for their care or if the insurance had covered everything. The study revealed a story of two different realities. On one hand, the insurance program was successful in its primary goal of removing financial barriers. More than four out of five women in the study reported that they did not have to pay a single cent out of their own pockets for their prenatal visits or their delivery. The program had reached a wide audience, covering women from both formal jobs and informal work, and it had successfully brought them into the healthcare system for check-ups.

However, the second part of the story showed that removing the cost was not enough to change where women gave birth. Despite having free access to care, the majority of the women still delivered their babies at home rather than in a clinic or hospital. Only about one in four women gave birth in a medical facility, while the remaining three-quarters delivered at home. The study found that this outcome was not random; it was deeply tied to a woman's education and her location. Women who had attended university were far more likely to give birth in a facility, while those with little or no formal education were much less likely to do so. Similarly, women living in rural areas were much less likely to use a hospital for delivery compared to those living in cities.

The researchers also discovered that the timing and frequency of the check-ups mattered greatly. Women who started their prenatal care early in their pregnancy and visited the doctor at least four times were significantly more likely to give birth in a facility. Those who waited until later in the pregnancy to start their care, or who visited the doctor fewer than four times, were much less likely to deliver in a facility. This suggests that once a woman is engaged with the healthcare system and trusts the process, she is more likely to complete the journey with a professional delivery. The data also showed that where a woman started her care influenced where she ended up; those who began at a primary clinic often stayed there, while those who started at a larger hospital or private clinic tended to finish their journey there.

The study concluded that while the health insurance scheme in Kano State is a powerful tool for getting women to the clinic for check-ups, it cannot fix the problem of low facility delivery rates on its own. The financial barrier is gone, but other obstacles remain. The researchers suggest that the gap between having insurance and actually delivering in a hospital is likely due to issues on the supply side, such as gaps in infrastructure and operational bottlenecks that cause patients to bypass Primary Health Care facilities. For the insurance to truly save lives, it must be paired with stronger health centers that are ready to welcome these women when they are ready to give birth. The findings highlight that achieving the goal of safe motherhood requires a complete system where financial protection meets reliable, high-quality care, ensuring that every woman, regardless of her education or where she lives, has a safe place to bring her child into the world.