EFFECT OF RISING COST OF LIVING ON ANTENATAL CLINIC ATTENDANCE IN GENERAL HOSPITAL MINNA, NIGER STATE

CHAPTER ONE

ABSTRACT

Background: The escalating cost of living in Nigeria, driven by inflation, currency devaluation, fuel subsidy removal, and rising food and commodity prices, has placed enormous financial pressure on Nigerian households. For pregnant women, these economic pressures translate directly into reduced capacity to prioritise and afford antenatal care services, with potentially devastating consequences for maternal and neonatal health outcomes. General Hospital Minna, the principal secondary health facility in Niger State's capital, serves a large population of pregnant women from diverse socioeconomic backgrounds.

Objective: This study investigates the effect of the rising cost of living on antenatal clinic attendance among pregnant women at General Hospital Minna, Niger State.

Methods: A descriptive cross-sectional study design was employed. Data were collected from 320 pregnant women using structured questionnaires and key informant interviews with midwives and antenatal clinic staff. SPSS version 26 was used for data analysis.

Expected Findings: The study expects to find a significant reduction in antenatal clinic attendance frequency, increased missed visits, and delayed initiation of ANC among pregnant women facing financial hardship, with transportation costs and consultation fees identified as primary barriers.

Conclusion: Addressing financial barriers to antenatal care attendance requires targeted interventions including conditional cash transfers, subsidised transportation, and exemption of pregnant women from healthcare fees at public facilities.

Keywords: Cost of living, antenatal clinic, attendance, pregnant women, General Hospital Minna, Niger State, financial barriers, maternal healthcare.

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Antenatal care (ANC) is one the most cost effective interventions available to reduce maternal and neonatal mortality and morbidity. Regular attendance at antenatal clinic allows for early detection of obstetric risk factors, management of pregnancy complications, and provision of prevention interventions (intermittent preventive treatment, tetanus immunisation) and preparation for a safe delivery (WHO, 2016). WHO has suggested that at least 8 ANC contacts are required during pregnancy with the first visit ideally before 12 weeks gestation. However, in Nigeria, numerous data indicate that socioeconomic factors are the most omnipresent challenge not only for pregnant women not going for antenatal care, but for fewer than the recommended number of visits (National Population Commission [NPC] & ICF, 2019).

The economy of Nigeria has been declining drastically in the last few years. Gummit cut petrol subsidy in May 2023 leading to an instant rise of petrol prices that trickled down into rising transportation, food prices, and prices for critical goods and services. In May 2024, the official inflation rate in Nigeria advanced to 33.95%, an unusually high rate for the last few decades, while food inflation rose above 40% (National Bureau of Statistics [NBS], 2024). The economic circumstances of low-income households, which make up the bulk of patient users at General Hospital Minna, have severely limited people's disposable income and have forced them to make impossible decisions on how to allocate their budgets between paying for food, school fees, and healthcare.

Niger State is located in the North Central geopolitical zone with more than 52% poverty index among the states of gross poverty level in Nigeria (NBS, 2022). The population in the state capital of Minna is a mix of urban and peri-urban residents with many involved in both the informal economic sector activities (such as petty trading, artisanship and subsistence farming). In this context, the expenses for women who are pregnant or postpartum to access antenatal services for their own and their baby's health, such as registration, consultations, lab fees, ultrasound scans, transport and prescribed medications, may be too great to manage.

The main secondary health facility in Niger State capital is the General Hospital, Minna which is also a major provider of antenatal care to thousands of pregnant women in the state every year. The cost of living, which is an informal indication, has also reduced attendance among midwives in the antenatal clinic at the clinic, which is viewed as a contributor to the derogatory trend in attendance. There is, however, no systematic empirical data that quantifies the relationship between increasing cost of living and attending antenatal clinic at General Hospital Minna as of the current time. This study aims to produce that evidence and to help guide targeted institutional, state and national policy interventions.

A strong link has long been established between poverty and low maternal health status in the world health literature. Women in low-income families are disproportionately impacted by maternal mortality and being unable to access healthcare for a family is a key proximate cause (Say et al., 2014). Women living in the lowest quintile are consistently found to be less able to access ANC visits, have fewer nurse-ledbirths and less use of PNC than their wealthier counterparts in Nigeria, as shown in the wealth quintile analyses from the Demographic and Health Survey (DHS) (NPC & ICF, 2019).

The economic drivers of attendance of antenatal care are at play in various ways. Direct costs are those associated with registration fees, consultation fees, prescribed drugs/supplements, laboratory/diagnostic fees, and transportation to and from health facility. Other costs include cost of childcare of other children, opportunity cost of time spent waiting to go to the antenatal clinic and lost working income in companies of working women (Okonkwo et al., 2022). These multiple costs can effectively render antenatal care inaccessible, especially when economic stress is highest, in low income households where all expenses need to be carefully prioritised.

These economic challenges have been compounded by the macroeconomic environment of Nigeria for 2023–2024. Some measures introduced as part of the unification of the foreign exchange rate and petrol subsidy removal in the middle of 2023 had their immediate effects and caused a lot of pressure for inflation. Between June 2023 and January 2024, the naira's value declined by around 70% against the US dollar, while the consumer price inflation rate hit record levels (NBS, 2024). These macro-economic shocks have affected the behaviour of women seeking health services during pregnancy in Nigeria, but this is a question not yet adequately explored.

The external health system context is an additional complexity in Niger state. In Nigeria, access to free maternal care services is theoretically provided for under the Midwives Service Scheme, and some states offer exemption policy, however, access to free maternal care services is not always available and unofficial charges are widespread at public health facilities (Okonkwo et al., 2022). Niger State (with Minna the most appropriate study area) is an area of critical importance to explore the relationship between economic conditions and antenatal care attendance, based on their high poverty burden, macro-economic instability and inadequate healthcare financing policy.

1.2 STATEMENT OF THE PROBLEM

In the case of pregnant women in Minna, Niger State, the cost of living in Nigeria is an immediate and direct threat to the attendance of pregnant women at antenatal care, especially if recent changes in macroeconomic policies are taken into consideration. It was noted that the decline of the attendance at antenatal clinics has been observed at General Hospital (Minna) and that it has been related to the worsening of the economic situation. Socio-economic factors such as the cost of transportation has been reported to be a key barrier for pregnant women attending the clinic for the failure to attend these clinics during their pregnancy, and not being able to afford the prescribed medications and laboratory tests.

If this trend of poor antenatal attendance can be corroborated from the data, then there is a high risk of increase in maternal and neonatal morbidity and mortality in the catchment area of the General Hospital Minna because women who do not attend antenatal are likely to experience complications which are not detected in time, receive preventive intervention or be adequately prepared for delivery in the hospital. But the absence of empirical evidence on this relationship makes it hard for hospital administrators and state health officials to develop targeted interventions or advocate for emergency funding provisions for health care. This study directly tackles this important evidence gap.

1.3 OBJECTIVES OF THE STUDY

The general objective is to assess the effect of the rising cost of living on antenatal clinic attendance among pregnant women at General Hospital Minna, Niger State.

Specific objectives are to:

1. Determine the pattern of antenatal clinic attendance among pregnant women at General Hospital Minna.
2. Assess the self-reported financial burden of antenatal care on pregnant women attending General Hospital Minna.
3. Identify the specific cost components of antenatal care that most significantly impede attendance.
4. Examine the relationship between household income levels and frequency of antenatal clinic attendance.
5. Assess the strategies employed by pregnant women to cope with financial barriers to antenatal care attendance.

1.4 RESEARCH QUESTIONS

1. What is the pattern of antenatal clinic attendance among pregnant women at General Hospital Minna?
2. What financial burden do pregnant women at General Hospital Minna associate with antenatal care attendance?
3. Which specific cost components of antenatal care most significantly impede attendance at General Hospital Minna?
4. Is there a significant relationship between household income levels and frequency of antenatal clinic attendance at General Hospital Minna?
5. What strategies do pregnant women employ to cope with financial barriers to antenatal care attendance?

1.5 RESEARCH HYPOTHESES

H01: There is no significant relationship between the rising cost of living and antenatal clinic attendance among pregnant women at General Hospital Minna.

H02: There is no significant association between household income level and frequency of antenatal clinic attendance at General Hospital Minna.

H03: Transportation cost has no significant effect on the number of antenatal visits made by pregnant women at General Hospital Minna.

1.6 SIGNIFICANCE OF THE STUDY

This study has important implications for clinical practice, health service administration, health financing policy, and public health advocacy. For midwives and antenatal care providers at General Hospital Minna, the findings will illuminate the financial dimensions of their patients' circumstances, enabling more empathetic and practically supportive counselling including advice on leveraging available exemption schemes, community support networks, and affordable transportation options.

For hospital administrators, the findings will provide evidence to advocate to the Niger State Ministry of Health for expanded fee waiver programmes, conditional cash transfer linkages with ANC attendance, and support for transport voucher schemes. At the state level, findings will contribute to Niger State's Maternal and Child Health Programme by identifying the economic dimensions of antenatal care utilisation, enabling targeted resource allocation and policy design.

At the national level, this study adds to the growing evidence base on the impact of Nigeria's economic crisis on healthcare access and outcomes, supporting advocacy for sustained government investment in healthcare financing mechanisms that protect vulnerable pregnant women from financial barriers to care. For the midwifery profession, the study emphasises the importance of considering the socioeconomic determinants of health in midwifery practice and reinforces the role of midwives as advocates for their patients' access to care.

1.7 SCOPE OF THE STUDY

This study is conducted at the antenatal clinic of General Hospital Minna, Niger State. The study population consists of pregnant women at any gestational age who are registered and attending the antenatal clinic at the time of data collection. The study focuses specifically on the relationship between the rising cost of living and antenatal clinic attendance, examining economic factors such as transportation costs, consultation and registration fees, drug and laboratory costs, and household income. The study does not extend to delivery or postnatal services, to other hospitals in Niger State, or to community-level antenatal care programmes. The study is conducted during the 2024 academic session and is contextualised within the macroeconomic conditions prevailing at that time.

1.8 LIMITATIONS OF THE STUDY

Several potential limitations are acknowledged. First, self-report bias may affect participants' disclosure of their true financial situations and health-seeking behaviours, as some women may be reluctant to disclose economic hardship. Second, seasonal variation in attendance patterns at General Hospital Minna related to agricultural cycles, cultural events, or healthcare system disruptions may influence the data if the study is conducted during an atypical period. Third, as a single-facility cross-sectional study, findings may not be fully generalisable to all public health facilities in Minna or across Niger State. Fourth, the rapidly evolving macroeconomic environment in Nigeria means that findings may reflect a specific economic moment and require updating as conditions change. These limitations will be addressed through transparent sampling procedures, anonymous data collection, and careful contextualisation of findings.

1.9 DEFINITION OF TERMS

Cost of Living: The amount of money required by an individual or household to sustain a certain standard of living, including expenditure on food, housing, transportation, healthcare, education, and other essential goods and services (NBS, 2024).

Antenatal Clinic Attendance: The act of a pregnant woman visiting a formal healthcare facility for scheduled antenatal consultations, monitoring, and health education, as recommended by the WHO and Nigeria's standard of care protocols (WHO, 2016).

Financial Barrier: Any economic factor that inhibits or prevents a pregnant woman from accessing or consistently utilising antenatal care services, including direct costs such as consultation fees, drug costs, and transportation, as well as indirect costs such as lost income and childcare expenses (Okonkwo et al., 2022).

Inflation: A sustained general increase in the prices of goods and services in an economy, resulting in a decrease in the purchasing power of money (NBS, 2024).

Household Income: The total income received by all members of a household from all sources including wages, salaries, informal sector earnings, remittances, and government transfers, typically measured per month (NPC & ICF, 2019).

Missed Antenatal Visit: A scheduled antenatal appointment that a pregnant woman fails to attend, which may result in gaps in clinical monitoring, preventive care, and health education (WHO, 2016).

Antenatal Care (ANC): The care provided by skilled healthcare professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy (WHO, 2016).

Transportation Cost: The amount of money expended by a pregnant woman in travelling to and from a health facility for antenatal care services, including costs of public transport, motorcycle taxis (okadas), or private vehicle fuel (Okonkwo et al., 2022).

Fee Waiver: A formal or informal policy that exempts pregnant women from paying for specified healthcare services at public health facilities, as part of a broader effort to remove financial barriers to maternal healthcare access (Federal Ministry of Health Nigeria, 2021).

REFERENCES

Federal Ministry of Health Nigeria. (2021). National health sector development plan 2021–2025. Federal Ministry of Health.

National Bureau of Statistics. (2022). Nigeria multidimensional poverty index 2022. NBS. https://www.nigerianstat.gov.ng

National Bureau of Statistics. (2024). Consumer price index May 2024. NBS. https://www.nigerianstat.gov.ng

National Population Commission & ICF. (2019). Nigeria demographic and health survey 2018. NPC and ICF. https://www.dhsprogram.com

Okonkwo, A. D., Okeke, C. C., Obi, S. N., Ifeadike, C., & Ezeoke, O. (2022). Financial barriers to antenatal care utilisation in Southeast Nigeria: Implications for health equity. African Journal of Reproductive Health, 26(2), 34–43. https://doi.org/10.29063/ajrh2022/v26i2.4

Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A. B., Daniels, J., ... & Alkema, L. (2014). Global causes of maternal death: A WHO systematic analysis. The Lancet Global Health, 2(6), e323–e333. https://doi.org/10.1016/S2214-109X(14)70227-X

World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. WHO Press.