The World Health Organization originally advised pregnant women to attend at least four antenatal visits, a target that shaped maternal health programming across sub-Saharan Africa for decades. In 2016, however, the organization overhauled its guidance, replacing the four-visit model with a recommendation of eight or more individual contacts with a health provider over the course of pregnancy. The change reflected growing evidence that more frequent contact allows clinicians to detect complications such as preeclampsia, anemia, and fetal growth restriction earlier, and to intervene before they become fatal. The revised standard also shifted the language from ‘visits’ to ‘contacts’ to emphasize that every interaction between a pregnant woman and her health system matters.

Most research on antenatal care in Nigeria has relied on a binary measure, simply asking whether a woman attended any sessions at all or at least four. That approach, the study’s authors argue, obscures how far along the care continuum women actually progress and makes it impossible to track national movement toward the current WHO guideline. To close that gap, the research team from Obafemi Awolowo University and Federal University Birnin Kebbi categorized utilization into three ordered levels: fewer than four visits, four to seven visits, and eight or more visits. This ordinal framework allowed them to simultaneously evaluate adherence to both the old and new WHO benchmarks and to identify which factors push women across each successive threshold.

The data set covered women aged 15 to 49 who had at least one live birth in the reference period, a nationally representative sample designed to reflect Nigeria’s enormous demographic and geographic diversity. The descriptive results alone paint a sobering picture. Among all women surveyed, 47 percent reported fewer than four antenatal visits for their most recent pregnancy, 36 percent reported four to seven visits, and a mere 17 percent attained eight or more contacts. Combined with the 28 percent who received no care whatsoever, the figures mean that fewer than one in five Nigerian pregnancies currently meet the international standard that global health authorities consider the minimum for protecting maternal and newborn lives.

To understand who reaches each level of care, the researchers employed a generalized ordered logistic regression model, a statistical technique suited to outcomes that fall along a natural hierarchy. Unlike a standard logistic regression that collapses the outcome into two categories, the generalized ordered model estimates how each sociodemographic factor relates to crossing each cumulative threshold, from no care to any care, from minimal to adequate care, and from adequate to the full WHO-recommended schedule. The model adjusted for a battery of confounders, and design-based chi-square tests were first used to confirm that utilization varied significantly across social and regional strata in the raw data.

Education emerged as one of the most powerful predictors of care. Women with higher education had more than five times the odds of achieving at least four antenatal visits compared with their less-educated counterparts, with an adjusted odds ratio of 5.33 and a 95 percent confidence interval of 4.26 to 6.66. Wealth told a similar but distinct story. Women in the richest households were more than four times as likely as the poorest to reach eight or more contacts, with an adjusted odds ratio of 4.38 and a confidence interval of 3.34 to 5.74. Intriguingly, the factors that help women cross the four-visit threshold are not always the same factors, or of the same magnitude, that carry them to the eight-contact level, a nuance the binary analyses of previous studies could never reveal.

Geography proved to be perhaps the starkest divider of all. Nigeria’s South West region, home to Lagos and some of the country’s best-resourced health infrastructure, showed dramatically better outcomes than the North Central zone used as the reference. Women in the South West had nearly seven times the odds of attaining eight or more antenatal visits compared with their North Central counterparts, with an adjusted odds ratio of 6.91 and a 95 percent confidence interval of 5.74 to 8.31. The pattern reflects deep, long-standing inequalities between southern and northern Nigeria in educational attainment, health facility density, and the availability of skilled birth attendants, divisions that shape health outcomes long before a woman ever becomes pregnant.

The implications of these findings reach well beyond Nigerian borders. As low- and middle-income countries begin to realign their maternal health monitoring systems with the 2016 WHO guideline, Nigeria’s experience offers a warning about how much progress may be masked when success is defined as four visits rather than eight. A country that appears close to universal basic antenatal coverage under the old standard may, in truth, be serving only a small fraction of pregnant women at the level now considered necessary. The authors suggest that policies aimed at improving utilization must simultaneously tackle socioeconomic and regional inequality while strengthening the supply side, ensuring that facilities exist, are stocked, and are staffed close enough to home for women to complete the full contact schedule.

For the roughly seven million Nigerian women who give birth each year, the arithmetic of the study translates into a concrete risk. Antenatal care is a key determinant of maternal survival because it is the principal channel through which danger signs are detected, iron and tetanus prophylaxis are delivered, hypertension is managed, and women are connected to skilled delivery services. Nigeria already accounts for a disproportionate share of the world’s maternal deaths, and the new analysis suggests that the country’s path to reducing that toll runs through both classrooms and clinics. Raising female educational attainment, narrowing the wealth gap, and investing specifically in the underserved northern regions would, the evidence indicates, do more to lift women from a handful of visits to the full recommended schedule than any single clinical intervention.

The study also demonstrates the value of the ordinal analytical approach itself. By modeling antenatal utilization as a graded outcome aligned with both WHO eras of guidance, the researchers produced estimates that policymakers can act on at every point along the care continuum, identifying where women drop out and which characteristics distinguish those who persist. The dataset was drawn from the Demographic and Health Survey Program, whose anonymized, publicly accessible surveys are conducted with approval from national ethical review boards and the ICF Institutional Review Board, with informed consent obtained from all participants. The research received no specific external funding, and the authors declare no competing interests. As Nigeria and its neighbors grapple with the gap between the four-visit past and the eight-contact future, this analysis provides both the baseline measurement and the analytical roadmap for tracking, honestly and precisely, whether the world’s most vulnerable pregnant women are finally getting the care they were promised.

Subject of Research: Sociodemographic and regional inequalities in antenatal care utilization in Nigeria relative to WHO guideline thresholds

Article Title: Inequalities in antenatal care utilization in Nigeria: an ordinal analysis aligned with WHO guidelines

Article References: Sani, J., Adesina, A. N., Awoniyi, A., Otitoju, O., Ajibade, T. O., Boboye, I., & Bisiriyu, L. A. (2026). Inequalities in antenatal care utilization in Nigeria: an ordinal analysis aligned with WHO guidelines. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15606-8

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15606-8

Keywords: antenatal care, Nigeria, WHO guidelines, maternal health, health inequalities, ordinal regression, Demographic and Health Survey, maternal health services, health services research, Africa, Inequalities, antenatal