Provision and experience of quality antenatal care services in public primary health care facilities in Nigeria: a mixed methods study using the WHO Quality of Care framework

Background Quality antenatal care (ANC) is essential for improved maternal and newborn health outcomes. Yet, providing quality ANC services remains challenging in Nigeria, with suboptimal ANC coverage and the highest global maternal deaths. Using the WHO quality of care framework, we assessed the provision and experience of quality ANC services in public primary healthcare (PHC) facilities in Nigeria and the associated determinants. Methods This convergent mixed-methods study was conducted in Anambra, Jigawa, and Kebbi states. We used a semi-structured questionnaire to conduct exit interviews with 1200 randomly sampled pregnant women accessing ANC services across 150 public PHC facilities in these states. Using semi-structured interview guides, we conducted 15 key informant interviews, 21 in-depth interviews, and 18 focus group discussions with purposively selected ANC healthcare workers (HCWs) and community members across the states. Quantitative data were analysed using descriptive statistics and logistic regression at p<0.05, and qualitative data were analysed thematically and triangulated with quantitative findings. Results Only 8.2% of participants received the recommended minimum quality of ANC services. Blood pressure measurement (76.5%) and blood testing (63.3%) were the most provided services, while tetanus vaccination (38.1%) and intestinal parasite drugs (14.0%) were the least. Satisfaction scores were 48.8-58.8% for service delivery, 46-48.8% for PHC resources adequacy, and 48.4-58.6% for interpersonal aspects of care. Free ANC services (aOR = 2.70; 95% CI: 1.5, 5.0), perceived expensive service (aOR = 3.76; 95% CI: 1.6, 8.5), urban residence (aOR = 1.72; 95% CI: 1.0, 3.0), attending ANC service due to personal choice (aOR = 1.87, 95% CI: 1.0, 3.5), accessible ANC information (aOR = 6.55, 95% CI: 1.8, 23.8; aOR = 5.95, 95% CI: 2.1, 16.8; and aOR = 8.98, 95% CI = 2.3, 33.2), and attaining primary school education (aOR = 3.18, 95% CI = 1.3, 9.9) were significantly associated with quality ANC, with long waiting times and insufficient HCWs and resources cited as major challenges. Conclusion Strengthening health systems, including recruiting and training HCWs, ensuring adequate resources, providing supportive supervision, and engaging communities, are essential to improving ANC quality. The WHO framework should also include socioeconomic factors influencing ANC provision and satisfaction.