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Background: Antenatal clinic attendance by pregnant women and utilization of skilled health care providers at delivery is still issues of major concern in developing countries including Nigeria. Nigeria Demographic and Health Survey (2013) noted that only 18% of pregnant women had their first antenatal clinic visit in the first trimester of pregnancy while 34% did not receive any antenatal care at all. The report also showed disparity between urban dwellers (23%) and (15%) rural dwellers with reference to antenatal clinic attendance in the first trimester of pregnancy. The choice of place for antenatal care and delivery, to a large extent influence pregnancy outcome for both mother and baby. Thus, positive maternal health seeking behavior contributes significantly to the reduction of the high morbidity and mortality associated with pregnancy and child birth especially in rural communities, of most developing countries.


The aim of the study was to assess maternal health seeking`behaviour and pregnancy outcome in rural communities in Enugu State in order to provide evidence based information for effective health education for the study population. Methods and Materials: TheCross-sectional descriptive survey design was used for the study. Validated researcher developed questionnaire and observation guide were the instruments used for data collection. Descriptive and inferential statistics were used to analyze data obtained using SPSS version 20 at 0.05 level of significance. Results: Majority of the respondents 165 (79.7%) booked for antenatal care during the first trimester of pregnancy, and 193 (93.2%) attended antenatal care in a health facility while only 7 (3.4%) did not attend antenatal care in a health facility nor visited a traditional birth attendant home. The study further revealed that 100 (48.3%) of the respondents attended secondary health care facilities (General Hospital) while 74(35.7%) attended primary health care facilities which were located within the communities. Out of the 207 pregnant women studied, 141 (68%) had health problems associated with pregnancy and all of them visited a secondary health care facility for treatment while only 42 (20.3%) visited a primary health care facility.Most of the mothers 172(83%) carried their pregnancies to term and had safe delivery. They were also healthy to take care of their babies while 35 (16.9%) were weak for self-care and care of their babies at birth. They however, gradually regained strength within one week postpartum. Baby’s outcome was good, 175 (84.5%) cried vigorously at birth, 31 (15%) had weak cry one minute at birth but picked up at 5 minutes after birth, however one baby 1 (0.5%) was stillborn. Age and educational level of respondents did not significantly influence their health seeking behaviour (p>0.05). But pregnancy outcome for baby and place of antenatal care showed significant association (p<0.05). Conclusion: The study concluded that maternal health seeking behaviour in the rural communities studied in Enugu was good as revealed in the positive pregnancy outcome for most of the mothers and their babies.However it was intriguing to find out that primary health care facilities which were located within the communities were poorly utilized by the mothers for antenatal care and delivery while secondary health care facility located at some distance from their homes had better patronage. It was therefore recommended that there is need to identify factors that hinder the use of primary health care facilities by pregnant mothers in the studied population and such factors should be addressed for better utilization by these rural women.


Pregnant women who attended a primary hospital were significantly more likely to have travelled 5 to 10 km from the hospital (vs >  10 km), reside in a rural area, or have a lower education level than those attending a secondary or tertiary hospital. Pregnant women attending a primary hospital were more likely to have travelled less than 5 km, waited less than 15 min to see a doctor (vs ≥ 60 min), have an unplanned pregnancy, no history of a complicated pregnancy, had one previous abortion (vs ≥ 2), or be aged < 35 years, than those who attended a tertiary hospital.

Conversely, women who attended a secondary hospital vs a primary hospital were more likely to believe it necessary to seek maternal healthcare and were more likely to have made the decision on the location of the delivery themselves. Women attending a tertiary hospital vs a primary hospital were more likely to have travelled to the hospital by public transport or taxi (vs on foot).


Andersen’s health behavioral model is the cornerstone of many studies assessing patient healthcare-seeking behavior and the accessibility of health services. The model has been used to improve healthcare services worldwide [111223]. Our results demonstrated that there were significant demographic/pregnancy and environmental factor differences among pregnant women attending primary, secondary and tertiary hospitals.

Several of the identified factors were consistent with the known risk factors for pregnancy, indicating that the national prenatal health service in China was functioning well at the time of the survey. For example, our study showed that pregnant women of advanced maternal age (AMA) (aged 35 years or older) were more likely to be attending a tertiary hospital than a primary hospital for antenatal care. AMA is widely recognized as a risk factor for pregnancy complications and adverse pregnancy outcomes [24,25,26]. Although we cannot determine the reasons for each hospital visit, the finding that advanced women were attending a tertiary hospital suggests that these women were receiving more specialized care.

Health Commission of Guangdong Province released that the incidence of ‘high risk pregnancies’ is increasing, and significantly so, from 12% in 2013 to 30% in 2015 [27]. At the beginning of 2016, the Chinese health and family planning commission implemented a ‘two-child policy’, which is expected to increase the number of pregnancies and births, particularly to older mothers. The current healthcare-seeking behavior findings suggest that this may put additional demand on tertiary hospitals; thus, early assessment of all pregnant women at primary or secondary hospitals should be encouraged in order to prioritize resource allocation most effectively and promoting the equity of healthcare-seeking behavior of pregnant women.

This study indicated that tertiary hospitals were more likely to be attended by pregnant women with a history of pregnancy complications, abortion, and who were having a planned pregnancy, than a primary hospital. The former two groups of pregnant women chose the tertiary hospitals mostly out of the consideration of their actual medical needs, in line with previous studies [28]. However, for those women with planned pregnancy, seeking healthcare in the tertiary hospitals probably only because of them being cautious and attentive to the needs of the current pregnancy, rather than medical needs, this may not be encouraged from the perspective of health equity. Interestingly, a New Zealand study has shown no difference of clinical outcomes of women giving birth in either a tertiary level maternity hospital or a freestanding primary level maternity unit [29]. This paper concluded that women’s experience of transfer to a primary hospital was generally positive, suggesting that patients can be reallocated between hospitals during pregnancy. For example, a patient attending a tertiary hospital could be asked to attend a primary hospital where the clinical conditions allow, freeing up specialized resources for those with the most need. For health system and standard hospital facilities are different in China, convenient reallocation are impossible in most areas currently. Thankfully, a series of policies are being carried out, which make it possible someday.

Our findings also showed women attending a secondary or tertiary hospital were more likely to reside in an urban area, or have received a higher level of education than those attending the primary hospital. These findings are similar to the earlier research of Yanikkerem et al [30]. Large differences in healthcare accessibility in urban and rural areas is commonly observed in many countries, for example the Philippines and Cambodia [3132]. In the province of Guangdong, China, the distribution of tertiary hospitals favors urban areas. Half of all tertiary hospitals are located in the city of Guangzhou, whereas most other cities in the region have one or no tertiary hospitals. According to the China Statistical Yearbook, 178 township health centers and 16 community health centers in Guangdong hadn’t delivered any babies during 2015, and 412 maternity beds were idle. This indicates that there is a large pool of unutilized resources in primary care locations. This study suggested that pregnant women with higher level of education were potential target for interrupting of healthcare seeking behavior.

Secondary hospitals are more likely to be attended by pregnant women who considere it necessary to seek maternal healthcare and who decide for themselves where to have their baby delivered. A study has previously suggested that spouses can intensely influence the maternal healthcare sought by a pregnant woman. Men typically are the primary earners and this often manifests as also having a strong influence in a wife’s medical care [3334]. The influence of family in a woman’s maternal healthcare is an interesting topic and deserves further study [35]. For the aspect of equity of health, assessing the health risks of pregnant women and diverting pregnant women without medical needs to primary health care institutions are main issues that need to be considered.

Our study also suggests that convenience may be an important part of women’s choice of hospital. Attendance at a tertiary vs a primary hospital was associated with women choose public transport/taxi as their mode of transport (compared with on foot). In China, these are also the main modes of transport mode in urban areas, where the tertiary hospitals are located. These factors demonstrate that patients in rural areas may find access to specialist medical attention to be more difficult, and this should be a consideration when defining future healthcare investment and policy. Long waiting times in tertiary hospitals is also an ongoing challenge for the national health service [36,37,38].

This research is limited in that it only analyzed selected, pre-defined, environmental and demographic/pregnancy characteristics. Other factors may also be important, but were not surveyed. As this is a cross-sectional study, the results may infected by respondent bias. The interplay between the factors in individual patients could not be assessed due to the nature of the analysis.


One environmental factor (urban vs rural living), and several demographic/pregnancy characteristics (a planned pregnancy, history of a complicated pregnancy, perceived necessity for maternal healthcare, number of prior abortions, woman’s age, highest education level, distance to the hospital, waiting time, mode of transport, power to make decision about delivery location) were found to be associated with pregnant women’s choice of hospital in Guangdong, China. To optimize the efficiency of the national health service, we have an idea that women with low risk pregnancies should be initially encouraged to attend a primary or secondary hospital for antenatal care, which could relieve the pressure on resources in tertiary hospitals. Of course, there are lots of tasks such as the safety, cost and efficiency of care delivered at various sites should be studied in future researches.

Availability of data and materials

All the data relevant for the manuscript are reported in tables. The raw data can be accessed from the corresponding author up on request.


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