Background: Maternal mortality remains a pressing global health challenge, with Nigeria contributing a significant share of the burden. Reproductive and maternal health (RMH) services delivered through primary health care (PHC) facilities are critical in addressing these outcomes. However, utilization of such services is often limited. This study assessed women’s perceptions of strategies for enhancing reproductive and maternal health service uptake in primary healthcare settings.
Methodology: This was a descriptive cross-sectional study conducted among 318 women attending the selected PHC facilities in Karu Local Government Area (LGA), Nasarawa State, in 2025. A multistage sampling technique was adopted for this study. Data were collected using a pretested, interviewer-administered structured questionnaire and analyzed using descriptive and inferential statistics.
Results: Utilization of reproductive and maternal health services (MHS) remained suboptimal among respondents, with only about half completing the recommended antenatal care visits or delivering in primary healthcare facilities. Key barriers included cultural beliefs, cost-related challenges, provider attitudes, privacy concerns, and perceptions of poor facility conditions. Family planning use was the only significant predictor of PHC service utilization (p = 0.016). Respondents strongly supported strategies such as improving facility infrastructure, reducing service costs, increasing the number of female health workers, strengthening community-based health education, and expanding government investment in PHC services.
Conclusion: Although awareness of reproductive and MHS was generally high, utilization remained suboptimal due to health system, economic, and sociocultural barriers. Strengthening PHC infrastructure, improving quality of care, enhancing community engagement, and implementing financial protection mechanisms may improve service uptake and contribute to better maternal health outcomes.

Reproductive health, Maternal health services, Knowledge, Antenatal care, Maternal morbidity and mortality.

Reproductive and maternal health (RMH) remain a cornerstone of public health and an important indicator of the overall performance of healthcare systems. Despite substantial global efforts to improve maternal health outcomes, maternal morbidity and mortality remain major public health challenges, particularly in low- and middle-income countries (LMICs). According to the World Health Organization (WHO), Nigeria contributes a significant proportion of global maternal deaths, with maternal mortality remaining unacceptably high despite ongoing interventions aimed at improving maternal healthcare access and utilization.[1,2]

The utilization of RMH services, including antenatal care, skilled birth attendance, postnatal care, and family planning services, is essential for reducing preventable maternal and neonatal morbidity and mortality. In Nigeria, primary health care (PHC) facilities serve as the first point of contact for healthcare and play a critical role in delivering these services, particularly to underserved and vulnerable populations.[3] Effective utilization of RMH services has been associated with improved pregnancy outcomes, early detection of complications, increased access to skilled care during childbirth, and improved maternal and child survival.[1,2]

Despite the availability of RMH services within many PHC facilities, utilization remains suboptimal in several parts of Nigeria. Previous studies have identified numerous barriers to service utilization, including inadequate infrastructure, shortages of skilled healthcare personnel, long waiting times, poor quality of care, stock-outs of essential medicines, financial constraints, cultural beliefs, low educational attainment, and limited decision-making autonomy among women.[4-7] These barriers often interact to reduce access to and utilization of essential MHS.

Addressing these challenges requires the implementation of strategies that are responsive to the realities and experiences of women who utilize RMH services. Understanding women’s perceptions of interventions designed to improve service uptake is important because women are the primary beneficiaries of reproductive and maternal healthcare services. Their perspectives provide valuable insights into the barriers they encounter and the strategies they consider most feasible, acceptable, and effective for improving service utilization.[8,9]

Several interventions have been implemented in Nigeria and other LMICs to improve RMH service utilization. These include strengthening PHC infrastructure, improving the availability and competence of healthcare workers, community-based health education, deployment of community health workers, financial protection mechanisms such as health insurance schemes and conditional cash transfers, and community mobilization activities aimed at increasing awareness and demand for maternal healthcare services.[10-14] Evidence suggests that interventions that are community-centered and responsive to local needs are more likely to achieve sustained improvements in service uptake and health outcomes.

Although previous studies have examined factors influencing RMH service utilization, there is limited evidence regarding women’s perceptions of strategies that could improve uptake of these services within primary healthcare settings in Karu LGA of Nasarawa State. Understanding these perceptions is important for informing policy decisions, strengthening maternal health programs, and designing interventions that are culturally appropriate, acceptable, and sustainable. Therefore, this study assessed women’s perceptions of strategies for enhancing reproductive and maternal health service uptake in primary healthcare settings in Karu LGA, Nasarawa State, Nigeria. The findings may contribute to efforts aimed at improving maternal health outcomes and advancing progress toward Sustainable Development Goal 3, which seeks to ensure healthy lives and promote well-being for all at all ages.

Study area: The study was conducted in Karu LGA, Nasarawa State, North-Central Nigeria. Karu LGA shares boundaries with the Federal Capital Territory (FCT), Abuja, and has an estimated population of approximately two million people. The area is cosmopolitan, comprising diverse ethnic groups, and is served by several primary healthcare facilities that provide reproductive and maternal health services.

Research design: A descriptive cross-sectional study design was employed to assess the utilization of reproductive and MHS among women attending selected primary healthcare facilities in Karu LGA, Nasarawa State, Nigeria.

Study population: The study population comprised women of reproductive age (15-49 years) who had accessed reproductive and MHS in selected primary healthcare facilities in Karu LGA during the study period.

Inclusion criteria: Women aged 15-49 years who had utilized reproductive and MHS in the selected PHCs, including pregnant women attending antenatal care clinics and women who had delivered within the previous two years and who provided informed consent to participate.

Exclusion criteria: Women with severe cognitive impairment, hearing or speech difficulties, or medical conditions that limited their ability to participate effectively in the study were excluded.

Sample size determination: The sample size was determined using Cochran’s formula for estimating proportions:

n = Z²pq/d²
where Z = 1.96 at a 95% confidence level, p = 0.633, q = 0.367, and d = 0.05.

The calculated minimum sample size was 357 respondents. After adjusting for a 10% non-response rate, the final sample size was 393 respondents. However, only 318 complete questionnaires were retrieved and found suitable for analysis, resulting in a response rate of 80.9%.

Sampling technique: A multistage sampling technique was employed.

Stage 1: Selection of Wards. Five wards were selected from the eleven wards in Karu LGA using simple random sampling by balloting without replacement.

Stage 2: Selection of Primary Healthcare Facilities. One functional primary healthcare facility was selected from each selected ward using simple random sampling, resulting in five PHCs.

Stage 3: Allocation of Sample Size, the sample size was proportionately allocated to the selected PHCs based on their average monthly attendance of women accessing reproductive and MHS.

Stage 4: Selection of Respondents, eligible women attending reproductive and maternal health clinics in the selected facilities were recruited using systematic sampling. The first respondent was selected randomly, after which every kth eligible woman was recruited until the required sample size was attained.

Data collection instrument and procedure: Data were collected using a pretested, structured interviewer-administered questionnaire developed from relevant literature. The questionnaire comprised sections on socio-demographic characteristics, knowledge of reproductive and MHS, utilization of services, barriers to utilization, and suggested strategies for improving service uptake.

The questionnaire was pretested among women of reproductive age in a community outside the selected study sites. Findings from the pretest were used to refine the wording, clarity, and sequence of questionnaire items before commencement of the main study.

Research assistants were trained in the study objectives, ethical considerations, questionnaire administration, and data collection procedures to ensure uniformity in data collection.

Data management and analysis: Completed questionnaires were checked for completeness, coded, and entered into Microsoft Excel before being exported to the IBM Statistical Package for the Social Sciences (SPSS) version 25 for analysis. Descriptive statistics were used to summarize the data, while chi-square tests and logistic regression analyses were used to assess associations and predictors of reproductive and maternal health service utilization. Statistical significance was set at p < 0.05.

Ethical Consideration (NHREC/21/05/2005/01506)
Ethical approval was obtained from the Bingham University Teaching Hospital Research Ethics Committee (BHUTHREC) (Approval No: NHREC/21/05/2005/01506). Permission was obtained from the Karu LGA Primary Health Care Department. Written informed consent was obtained from all participants before data collection, and confidentiality was maintained throughout the study.

Limitation of the study: The study is focused on Karu LGA, so findings may not apply to other regions with different socioeconomic or healthcare conditions. Potential recall bias due to self-reported data, the study’s reliance on healthcare facility data may not capture individuals who do not access healthcare facilities. Also, due to ethical considerations, the study only focuses on women of reproductive age (15-49 years). Thus, the study is limited in that the views of women below the age of 15 years and above 49 years will not be included in the study, and thus, the expected research results cannot be generalized outside the sample population of women aged 15-49 years.

Table 1: Barriers affecting the utilization of RMH services in PHC

Don’t like vaginal examinations: A notable 95 (29.9%) of respondents expressed that they “don’t like vaginal examinations,” while 177 (55.7%) did not view them negatively.

Mistreatment by healthcare workers: Acknowledged by 61 (19.2%) of respondents, while 202 (63.5% disagreed).

Previous negative experiences with facility-based care: 85 (26.7%) of respondents affirmed, and 56 (17.6%) were unsure.

Unequal treatment: 71 (22.3%) of respondents reported it, and 200 (62.9%) did not report it.

Lack of confidentiality was cited by 52 (16.4%) of women as a concern, with 216 (67.9%) disagreeing.

Inability to acquire required delivery items was reported as a barrier by 84 (26.4%) of respondents. 182 (57.2%) reported no such difficulty.

Table 2: Opinion on strategies to improve RMH service use in PHCs

Reducing the cost of services: A dominant majority, 254 (79.9%), of respondents agreed that reducing the cost of services would increase the use of PHC services. Only 34 (10.7%) disagreed, and 30 (9.4%) were unsure.

Provide health education in local languages in your community: 246 (77.4%) supported the idea of providing health education in local languages. Only 10.1% disagreed.

The government should invest more in PHC facilities: 264 (83.0%) respondents supported the idea that the government should invest more in PHC facilities. With only 22 (6.9%) disagreeing, this item received one of the strongest endorsements among all variables in the table.

More female health workers should be employed: Likewise, 254 (79.9%) of respondents believed that more female health workers should be employed.

Improve facility structure and equipment: An overwhelming 286 (89.9%) agreed that facility structures and equipment need to be improved, with only 4.1% disagreeing.

Create more awareness using radio, churches, and mosques: 278 (87.4%) of women also supported the use of radio, churches, and mosques for creating more awareness.

Will refer PHC services to more women: 288 (90.6%) of respondents said they would refer PHC services to other women if improvements were made.

Will attend PHC more often if these changes were made: 275 (86.5%) of respondents stated that they would attend PHC facilities more often if the recommended changes were implemented.

Table 3: What can be done to improve RMH service use in PHCs

The provision of financial incentives can improve the utilization of MHS: A substantial 295 of respondents (85, 26.7%) strongly agree, and 207 (65.1%) agree that the provision of financial incentives could improve MHS utilization. Only a combined 2.8% disagreed or strongly disagreed, while 5.3% remained neutral.

The provision of conditional cash transfers may encourage MHS: Conditional cash transfers (CCTs) were viewed favorably by the majority, with 77.1% (25.5% strongly agreeing and 51.6% agreeing). However, a slightly higher proportion (9.4%) disagreed.

Provision of community-based health insurance also met with strong approval: 274 (87.4%) of respondents agreed or strongly agreed that such a scheme could encourage maternal service use.

Provision of free MHS: 282 (37.7% strongly agree, 50.9% agree) respondents backing it. Only 3.5% disagreed.

Community mobilization for MHS: supported by 265 (36.8% strongly agree, 46.5% agree) respondents.

Engagement of community health influencers and promoters: supported by 271 (85.2%) respondents.

Respondents identified several strategies that could enhance the uptake of reproductive and MHS in primary healthcare facilities. The most strongly supported strategies included improvements to facility infrastructure and equipment, reductions in service costs, recruitment of additional female health workers, and the provision of health education in local languages. These findings reflect women’s experiences and perceptions regarding barriers to service utilization and practical approaches for improving access to care.

Respondents’ perceptions of strategies that would enhance the uptake of RMH services strongly emphasized health system strengthening and community participation. The majority of the respondents would advocate for improvement in facility infrastructure and equipment (89.9%), reducing the cost of services (79.9%), employing more female health workers (79.9%), and providing health education in local languages (77.4%). These perceptions reflect a pragmatic understanding of the barriers women face and are also in line with the principles of people-centered PHC delivery advocated by the Federal Ministry of Health.[3] Indeed, there is documentation of similar recommendations by Rosato et al. who show that strengthening ward development committees and community involvement greatly improved maternal health outcomes.[13]

In addition, over 80% of respondents advocated for more government investment in PHC facilities, reflecting public recognition of a need for systemic support. The call for community-based health insurance (87.4%) and conditional cash transfers (77.1%) has resonance with evidence from both Ethiopia and Kenya that such demand-side financing mechanisms improve maternal service uptake and reduce catastrophic health expenditure.[11,15] The strong support for community mobilization through religious and social platforms, 87.4%, also suggests that culturally sensitive and locally adapted health promotion strategies are desired. This confirms the assertion by Olaniran et al. that community health workers and influencers bridge the gap between the formal health system and local populations.[10]

The preference expressed for more female health workers also suggests that gender dynamics are a critical determinant of care utilization. Most women, especially in conservative or rural settings, would feel more at ease with female providers during childbirth and reproductive consultations. This finding is consistent with previous studies by Atela et al. showing that women often prefer female healthcare providers for reproductive and MHS because of privacy concerns, cultural sensitivity, and increased comfort during care.[16] Such sociocultural sensitivities need to be addressed to build trust and encourage repeat facility visits. Collectively, these findings imply that the pathway toward improving RMH service uptake is multifaceted in design, addressing both demand- and supply-side constraints. There is a need for culturally relevant education to increase awareness on the demand side, dispel myths, and encourage male involvement. On the supply side, there must be investment in infrastructure, human resources, and quality assurance mechanisms in a way that reinstates public confidence in PHC facilities. Additionally, financial protection strategies involve offering free MHS, community insurance, and targeted cash transfers to reduce economic barriers. In other words, this research reiterates that women’s perspectives can inform feasible and sustainable approaches to improving reproductive and maternal health service utilization. Their voices underline how important inclusive, context-specific, and gender-sensitive approaches are in PHC policy and program design. The implementation of these recommendations may improve the uptake of reproductive and MHS and contribute to progress toward achieving Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all ages.

Recommendations
Respondents’ recommendations for improving reproductive and maternal health service utilization

• To the Federal and State Governments: Investment in primary healthcare infrastructure should be increased: There is a need for adequate funding to rehabilitate and equip PHC facilities with essential supplies, delivery kits, and functional equipment for the improvement of quality service and user confidence. Implement financial protection mechanisms by introducing or scaling up community-based health insurance schemes and conditional cash transfer programs that target pregnant women and poor households as a means of eliminating financial barriers to care. Strengthen human resources for health by developing incentive-based recruitment and retention schemes to attract skilled birth attendants and midwives in rural PHCs, with attention to gender balance through the employment of more female health workers where culturally appropriate. Strengthen health governance and accountability by setting up periodic supervision and performance monitoring systems for PHC centers to ensure transparency, responsiveness, and quality in service delivery.
• To the Federal Ministry of Health and National Primary Health Care Development Agency: Scale up community-based health education programs: Support structured campaigns to promote antenatal care, facility-based delivery, postnatal care, and family planning, using local languages and trusted community platforms such as radio, mosques, and churches. Integrate the delivery of RMH services by enhancing the linkage of antenatal, delivery, postnatal care, and family planning to ensure continuity of care and minimize missed opportunities. Promote gender-sensitive care: Training health workers on respectful maternity care and gender sensitivity will address cultural and privacy concerns that discourage service uptake. Institutionalize community engagement through the involvement of community leaders, women’s groups, and other local influencers in PHC planning, monitoring, and feedback mechanisms.
• To primary health care facilities and local health authorities: Improve the patient experience and confidentiality: Facility managers should ensure privacy during examinations, respect in communication, and equal treatment for all women regardless of background and belief. Strengthen the capacity of the staff by providing regular in-service training for PHC workers on emergency obstetric care, interpersonal communication, and culturally competent service delivery. Ensure availability of essential supplies: Establish a functional supply chain and monitoring system to avoid stock-outs of medicines and delivery materials. Community outreach promotion: PHCs should work with community health volunteers, traditional birth attendants, and ward development committees in conducting outreach programs that bring services closer to women.
• To community leaders and religious institutions: Encourage positive health-seeking behaviour: Community and religious leaders should leverage their influence to discourage harmful traditional practices, support facility-based deliveries, and promote ANC and PNC attendance. Empower community participation by strengthening the role of ward development committees in identifying barriers at the local level, mobilizing community resources, and ensuring collective ownership of PHC programs. Support culturally sensitive advocacy: Promote local dialogue, which harmonizes faith and cultural norms with evidence-based health practices.
• To Non-Governmental Organizations (NGOs) and Development Partners: Support capacity building and infrastructure: Work with government and local authorities in developing appropriate PHC infrastructure, conduct training of frontline workers, and provide technical support to implement maternal health programs. Empower community mobilization by designing interventions appropriate to the context, such as maternal health education, women’s empowerment programs, and/or transport support for emergency obstetric care. Conduct advocacy and research: Work with policymakers to create evidence for and push sustainable policies supporting universal access to RMH services.

Limitation of the study: This study was limited to women attending selected primary healthcare facilities in Karu LGA and may not fully represent women who do not utilize PHC services. In addition, the use of self-reported information may have introduced recall bias. Therefore, the findings should be interpreted with caution when generalizing to other populations or settings.

This study assessed women’s perceptions of strategies for improving the uptake of reproductive and MHS in primary healthcare facilities in Karu LGA, Nasarawa State. The findings showed that though awareness was generally high, utilization remained suboptimal, and only about half of the respondents completed the recommended number of antenatal visits or delivered in PHC facilities. Some major deterrents to utilization were observed to be cultural beliefs, cost barriers, provider attitudes, and perceptions of poor facility conditions.

The key determinant of RMH service utilization was found to be family planning use, meaning that women who had accessed family planning tended to be better users of PHC services along the reproductive continuum. The study also identified strong support among respondents for proposed strategies focused on facility infrastructure improvements, increases in female and well-trained health workers, reduced service costs, and increased community awareness through culturally relevant media and local platforms.

Overall, the findings stress that improving the uptake of RMH services requires health system strengthening, community mobilization, and socio-cultural adaptation. Approaches that incorporate women’s perspectives, respect cultural contexts, and promote equity in access are more likely to yield sustainable improvements in reproductive and maternal health outcomes.

The authors acknowledge the women who participated in this study and the management and staff of selected primary healthcare facilities in Karu Local Government Area for their cooperation and support during data collection.

The authors received no specific funding for this research.

Corresponding Author:
Folashade Mary Otokpa
Department of Community Medicine & Primary Health Care
Bingham University, Karu, Nasarawa State, Nigeria
Email: [email protected]

Co-Author:
Kingsley Chinedu Okafor
Department of Community Medicine & Primary Health Care
Bingham University, Karu, Nasarawa State, Nigeria

Folashade Mary Otokpa conceptualized the study, collected and analyzed the data, and drafted the manuscript. Kingsley Chinedu Okafor supervised the study, contributed to the study design, reviewed the analysis, and critically revised the manuscript. Both authors read and approved the final manuscript.

Ethical approval was obtained from the Bingham University Teaching Hospital Research Ethics Committee (BHUTHREC) with approval number NHREC/21/05/2005/01506. Permission was obtained from the Karu LGA Primary Health Care Department before data collection.

The authors declared that they have no competing interests.

Dr. Kingsley Chinedu Okafor serves as guarantor of this study.

https://doi.org/10.63096/medtigo3062430

Otokpa FM, Okafor KC. Assessment of Women’s Perceptions of Strategies for Enhancing Reproductive and Maternal Health Service Uptake in Primary Healthcare Settings in Karu Local Government Area, Nasarawa State, Nigeria. medtigo J Med. 2026;4(2):e3062430. doi:10.63096/medtigo3062430 Crossref