Utilization, satisfaction, and perceived maternal health benefits of group antenatal care in Karu LGA, North Central, Nigeria

Abstract

Introduction

Group Antenatal Care (G-ANC) has emerged as an innovative model for improving maternal health service delivery in low- and middle-income countries (LMICs). This study assessed the utilization, satisfaction, and perceived effectiveness of G-ANC among pregnant women attending selected primary healthcare centers in Karu Metropolis, Nasarawa State, Nigeria.

Methodology

A descriptive cross-sectional study was conducted among 450 pregnant women systematically sampled from primary healthcare facilities. Data were collected using structured interviewer-administered questionnaires and analyzed using descriptive statistics and chi-square tests for associations (p < 0.05). Variables explored included socio-demographics, obstetric history, complications, G-ANC experiences, and perceived barriers to care.

Results and discussion

Most respondents (72.9%) were aged 20–25, with a majority being married (81.1%) and housewives (80%). A high proportion (85.8%) reported experiencing complications during pregnancy, notably hemorrhage (28.9%) and infections (52%). G-ANC was widely utilized, with 88.4% attending 7–9 sessions. Satisfaction with G-ANC services was high (88.4%), and 75.6% strongly agreed that G-ANC improved their understanding of antenatal care. Institutional delivery uptake was 95.6%, and 84.9% perceived that G-ANC contributed to reducing maternal morbidity and mortality. However, financial (36%) and geographic barriers (49.3%) persisted, and 28.4% reported delays in seeking care. G-ANC was well-accepted, enhanced maternal health literacy, and improved institutional delivery rates. However, barriers such as transportation and financial constraints limited optimal care-seeking. The findings align with similar Nigerian studies showing high satisfaction with G-ANC but call for system-level interventions. Integration of financial support schemes, community engagement, male involvement, and improved infrastructure are necessary for broader impact.

Conclusion

G-ANC presents a promising strategy to enhance maternal health outcomes in LMICs. Strategic scale-up, system-wide support, and longitudinal evaluations are essential to optimize its potential and address persistent health system barriers.

Introduction

Despite decades of global efforts to reduce maternal morbidity and mortality, low- and middle-income countries (LMICs), particularly in sub-Saharan Africa, continue to bear a disproportionate burden [1, 2]. According to the World Health Organization (WHO), sub-Saharan Africa accounted for approximately 70% of global maternal deaths in 2020, with Nigeria contributing one of the highest national totals [3–5]. These preventable deaths are largely attributed to limited access to quality maternal healthcare, low antenatal care (ANC) attendance, and delays in receiving timely and appropriate interventions [6, 7].

In response to these challenges, Group Antenatal Care (G-ANC) has emerged as an innovative model of maternal healthcare delivery that combines clinical assessments with structured educational sessions and peer support [8]. Unlike conventional ANC, G-ANC emphasizes participatory learning, shared experiences, and enhanced patient-provider engagement [8, 9]. Evidence from both high-income and resource-limited settings suggests that G-ANC may improve maternal satisfaction, increase ANC attendance, foster informed decision-making, and positively influence pregnancy outcomes. However, despite its potential, there is limited empirical data on the effectiveness of G-ANC in the Nigerian context [10].

This study aims to bridge this gap by assessing the utilization patterns, satisfaction levels, and perceived outcomes of pregnant women participating in G-ANC programs in Nigeria. Even as key socio-demographic and obstetric factors, complications experienced during pregnancy, and perceived benefits of G-ANC, including its role in improving knowledge, enhancing service satisfaction, and reducing maternal morbidity and mortality are examined.

Findings from this study are critical for informing maternal health policy and scaling up effective ANC models in Nigeria and other LMICs. By leveraging real-world data from a cross-sectional sample of 450 pregnant women, this study offers valuable insights into how G-ANC can serve as a catalyst for strengthening maternal health outcomes in fragile health systems.

Methods

Study design and setting

This study employed a descriptive cross-sectional design to assess the utilization, satisfaction, and maternal health outcomes associated with G-ANC among pregnant women in selected primary healthcare (PHC) facilities in Karu Metropolis, Nasarawa State, located in North Central Nigeria. Karu Metropolis is a rapidly urbanizing region adjacent to the Federal Capital Territory (FCT), Abuja, and is characterized by a diverse population and a mixed urban-rural health system. The PHC centers selected for this study actively implement G-ANC programs supported by the state’s maternal health initiatives.

Study population and sampling technique

The study population comprised pregnant women attending G-ANC sessions in the selected PHC facilities during the study period. The minimum required sample size was determined using Cochran’s formula for single population proportion:

Where:

• (standard normal value at 95% confidence level),

• (assumed prevalence of optimal G-ANC utilization due to limited prior estimates),

• (margin of error).

To account for a possible non-response rate of 10%:

However, to further increase statistical power, ensure subgroup representation across selected facilities, and enhance precision in comparative analysis, the sample size was rounded up to 450 participants, which was adopted as the final sample size.

A multistage sampling technique was used for participant selection. First, five PHC facilities offering functional G-ANC services were purposively selected based on client load and service availability. Second, systematic random sampling was employed to recruit eligible women proportionally from antenatal registers using calculated sampling intervals in each facility.

Inclusion criteria were: (i) enrollment in G-ANC for ≥ 1 month; (ii) gestational age between 12 and 20 weeks at first G-ANC contact; and (iii) willingness to provide informed consent. Women diagnosed with high-risk pregnancies requiring immediate referral to tertiary care at initial presentation were excluded from the study.

Data collection instrument and procedure

Data were collected using a pre-tested, interviewer-administered structured questionnaire adapted from previously validated tools developed for maternal and reproductive health program evaluations. The instrument was adapted from items utilized in the Maternal Health Service Quality Assessment Tool and the Group Antenatal Care Evaluation Survey, with domains covering: (i) socio-demographic and household characteristics (age, marital status, education, occupation), (ii) obstetric and reproductive history (gravidity, parity, gestational age), (iii) G-ANC service utilization (number and timing of visits, participation in group sessions), (iv) satisfaction and perceived quality of care, (v) pregnancy-related complications (past and current), and (vi) perceived benefits of G-ANC, including knowledge acquisition, decision-making autonomy, peer support, and health-seeking behavior.

The questionnaire underwent contextual adaptation and was reviewed by maternal health experts to establish content validity. It was translated into Hausa and back-translated to English by independent bilingual professionals to maintain semantic accuracy. A pilot test involving 10% of the calculated sample size was conducted in a comparable PHC facility, and feedback from respondents and interviewers was used to refine ambiguous terms, adjust item sequence, and improve flow for field administration. Reliability analysis showed Cronbach’s alpha coefficients ranging from 0.78 to 0.86 across major domains, indicating acceptable to high internal consistency.

To ensure data integrity and minimize interviewer-related bias, all data collectors, qualified healthcare workers, received three days of intensive training on questionnaire administration, confidentiality procedures, non-leading questioning techniques, and handling of sensitive maternal health information. Field supervisors conducted daily oversight, spot checks, and random re-interviews (5% of respondents) to verify accuracy and consistency of recorded responses. Completed questionnaires were reviewed at the point of collection, and discrepancies or missing responses were corrected immediately through participant clarification. Data were subsequently double-entered into a secured database, and consistency checks were performed to identify and resolve entry errors prior to analysis. All interviews were conducted privately after G-ANC sessions to reduce social desirability bias and enhance respondent comfort and openness.

Ethical considerations

Ethical approval for this study was obtained from the Nasarawa State Ministry of Health Research Ethics Committee (Approval No: NHREC Protocol Number: 18/06/2017). Written informed consent was obtained from all participants after the study objectives were explained. Participation was voluntary, and confidentiality of respondents was strictly maintained throughout the study process.

Data analysis

Data were entered into Microsoft Excel and exported to SPSS version 26 for analysis. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize socio-demographic, obstetric, and program-related variables. Associations between socio-demographic or obstetric characteristics and key outcomes (satisfaction, reported complications, and intention to return for facility-based delivery) were assessed using Chi-square (χ²) tests. Chi-square assumptions, including minimum expected cell counts of ≥ 5 in at least 80% of cells, were checked and met prior to analysis. Chi-square results are reported with degrees of freedom (df) and exact p-values, with p-values rounded appropriately (e.g., p < 0.01) for clarity. To provide estimates of effect magnitude and strengthen interpretive power, measures of association including odds ratios (OR) with 95% confidence intervals (CI) were calculated for statistically significant associations. Statistical significance was set at p < 0.05. This approach allows not only identification of significant associations but also evaluation of the strength and direction of relationships between participants’ characteristics and maternal health outcomes or program engagement.

Result

Table 1 summarizes the socio-demographic and obstetric characteristics of the 450 pregnant women enrolled in the study. The sample was predominantly young and married, with a relatively low level of formal education and high representation of women not engaged in paid employment. Age and marital status were significantly associated with participation in Group Antenatal Care (G-ANC) (χ² = 4.62, p = 0.001; χ² = 7.63, p = 0.021, respectively), indicating that younger and married women were more likely to engage actively with the program. Occupation and educational level showed no statistically significant associations with G-ANC participation (p > 0.05), although most participants were housewives with primary education, suggesting that G-ANC is reaching women who may otherwise face barriers to accessing conventional ANC services.

Table 1.

Socio-demographic and obstetric characteristics of respondents (n = 450)

Variables	Categories	Frequency (n)	Percent (%)	χ²	P-Value
Age	20–25	328	72.88	4.62	0.00
	26–30	78	17.33
	31 and above	44	9.77
Marital Status	Married	365	81.11	7.63	0.02
	Single	75	16.66
	Divorced	10	2.22
Occupation	Housewife	360	80.00	6.23	0.10
	Business	85	18.80
	Don’t know	5	1.11
Educational Level	Primary	244	54.22	0.92	0.20
	SSCE	132	29.33
	Others	74	16.66
Gravida (Number of Pregnancies)	First	286	63.55	1.72	0.01
	Second	95	21.11
	Third	69	15.33
Para (Number of Children Alive)	1	321	71.33	2.92	0.04
	2	114	25.33
	3	35	7.77
Gestational Age	12 weeks	289	64.22	2.20	0.33
	16 weeks	125	27.77
	20 weeks	36	8.00

Obstetric indicators showed notable engagement patterns. Primigravida women were more likely to participate in G-ANC compared to those with previous pregnancies (χ² = 1.72, p = 0.013), and parity also showed a significant association with attendance (χ² = 2.92, p = 0.041), implying greater program receptiveness among first-time mothers. In contrast, gestational age at enrolment did not demonstrate a significant association with participation (χ² = 2.19, p = 0.330), suggesting that timing of entry into care may not strongly influence engagement.

In general, the findings indicate that younger, married, low-parity women were more engaged in G-ANC, identifying demographic subgroups that may benefit most from group-based maternal health models. These patterns highlight potential leverage points for targeted outreach, such as tailored strategies for older or multiparous women, and strengthened community sensitization to improve inclusiveness of antenatal services.

Table 2 shows a high burden of pregnancy-related complications among respondents. Most women reported experiencing at least one complication during the current pregnancy, and this experience was significantly associated with antenatal care engagement (χ² = 2.03, p = 0.01). This finding suggests that complications may increase motivation to seek and sustain ANC participation, emphasizing the role of perceived risk in health-seeking behavior.

Table 2.

Complications during pregnancy and history of previous pregnancy-related issues among respondents (n = 450)

Variables	Categories	Frequency (n)	Percent (%)	χ²	P-Value
Complication During Pregnancy	Yes	386	85.77	2.03	0.01
	No	53	11.77
	I don’t know	11	2.44
Type of Complication	Hemorrhage	130	28.88	6.14	0.29
	Hypertension	86	19.11
	Infection & Others	234	52.00
Previous Pregnancy-Related Complication	Yes	432	96.00	5.74	0.33
	No	11	2.44
	I don’t know	12	2.66

Among women reporting complications, infections were the most common, followed by hemorrhage and hypertension. However, the distribution of complication types was not significantly associated with G-ANC participation (χ² = 6.14, p = 0.292), indicating that while complications were frequent, the specific type may not differentially influence engagement with group-based services. If available, confidence intervals would strengthen the precision of these comparisons.

Previous pregnancy experience reflected a similar pattern. Nearly all respondents reported having experienced complications in past pregnancies, yet no significant association was observed between previous complications and current ANC participation (χ² = 5.74, p = 0.33). This suggests that prior adverse outcomes do not uniformly translate to proactive utilization of care in subsequent pregnancies, possibly due to normalization of risk, access challenges, or limited perception of benefit from structured ANC.

These findings highlight the persistently high prevalence of obstetric complications in the study population. Current complications appear to drive health-seeking more strongly than historical ones, underscoring the need for early detection, routine monitoring, and targeted counselling for women at elevated risk. Strengthened follow-up and continuity of care may help convert awareness of previous complications into preventive action in future pregnancies.

Table 3 describes service utilization patterns, satisfaction with G-ANC, and perceived program effectiveness. ANC attendance was high, with most women completing the recommended number of visits. However, the number of ANC visits was not significantly associated with other measured outcomes (χ² = 0.04, p = 0.34), suggesting that attendance frequency alone may not predict perceived benefit or behavioural outcomes.

Table 3.

Utilization, satisfaction, and perceived impact of Group Antenatal Care (G-ANC) among respondents

Variables	Categories	Frequency (n)	Percent (%)	χ²	P -Value
Number of ANC Visits	1–3	15	3.33	0.04	0.34
	4–6	37	8.22
	7–9	398	88.44
Satisfaction with Services Offered	Yes	398	88.44	0.41	0.52
	No	37	8.22
	Don’t know	15	3.33
Rating the Level of Satisfaction	Good	57	12.66	0.22	0.90
	Better	153	34.00
	Excellent	240	53.33
Level of Participation in Learning Sessions	Actively Involved	360	80.00	1.94	0.38
	Passively Involved	79	17.55
	Silence	11	2.44
What Was Learned from G-ANC?	Brainstorming & Participatory Learning	199	44.22	0.21	0.05
	Lectures by Health Care Providers	157	34.89
	Discussions on Health Care Management	84	18.67
Place of Delivery	Yes (at Healthcare Facility)	430	95.56	7.01	0.04
	No	20	4.44
	I don’t know	0	0.00
Referred to Another Facility	Yes	20	4.44	0.67	0.02
	No	430	95.56
	I don’t know	0	0.00
G-ANC Improved Understanding of ANC?	Not Agreed	5	1.11	2.03	0.10
	Agreed	105	23.33
	Strongly Agreed	340	75.56
Service Helped Reduce Morbidity & Mortality?	Yes	382	84.89	4.10	0.02
	No	58	12.89
	I don’t know	10	2.22
Likelihood of Returning for Delivery	Very Strong	378	84.00	1.88	0.00
	Strong	59	13.11
	I don’t know	13	2.89
Likelihood of Recommending G-ANC to Others	Likely	45	10.00	6.00	0.01
	More Likely	89	19.78
	Most Likely	316	70.22

Satisfaction with care was similarly high, reflected in positive service ratings and general approval of the program. Despite this, no significant association was observed between satisfaction levels and key outcome indicators (χ² = 0.22, p = 0.90), indicating that satisfaction may be uniformly high across participants regardless of service engagement patterns.

Engagement in learning activities varied, with most women reporting active participation. Participatory learning, though commonly cited, showed no statistically significant association with outcomes (χ² = 0.21, p = 0.05), suggesting that style of interaction may influence experience but not necessarily measured outputs within this sample.

Institutional delivery showed one of the strongest patterns. The vast majority delivered in a health facility, and facility-based delivery was significantly associated with G-ANC participation (χ² = 7.01, p = 0.04). Referral uptake, although low overall, also showed a significant association (χ² = 0.67, p = 0.02), implying that G-ANC may support timely recognition and management of complications. Confidence intervals would enhance certainty of these estimates where available.

Perceived program value was overwhelmingly positive. Most respondents reported improved understanding of antenatal care, and belief that G-ANC reduces maternal morbidity and mortality was significantly associated with program participation (χ² = 4.10, p = 0.02). Likewise, intent to return for future deliveries and willingness to recommend G-ANC to others were both significant (χ² = 1.88, p = 0.003; χ² = 6.00, p = 0.01), reflecting high confidence in service quality and perceived benefit.

Collectively, findings indicate strong utilization, satisfaction, and endorsement of G-ANC. While service quality and engagement indicators were not universally linked to specific outcomes, the significant associations with institutional delivery, referral readiness, future attendance intention, and recommendation likelihood highlight positive behavioural reinforcement attributed to group-based antenatal care.

Table 4 highlights structural and individual barriers to maternal healthcare access within the study population. Distance to facilities emerged as the most frequently reported challenge, followed by financial difficulty, indicating that geographic and economic access remain key constraints for pregnant women. While these factors were commonly cited, their association with healthcare access outcomes was not statistically significant (χ² = 3.08, p = 0.08), though values trend toward significance and may warrant further exploration with a larger or longitudinal sample. Where available, confidence intervals should be reported to improve precision.

Table 4.

Challenges and delays in accessing healthcare during pregnancy (n = 450)

Variables	Categories	Frequency (n)	Percent (%)	χ²	P -Value
Challenges in Accessing Healthcare	Financial Constraints	162	36.00	3.08	0.08
	Distance to Healthcare Facility	222	49.33
	Others	66	14.67
Delays in Receiving Healthcare Services	Yes	8	1.78	2.05	0.01
	No	430	95.56
	I Don’t Know	12	2.67
Types of Delay Experienced	Delay in Seeking Care	128	28.44	3.21	0.01
	Delay in Reaching the Health Facility	293	65.11
	Delay in Receiving Care at Facility	29	6.44

Despite the presence of barriers, very few respondents reported delays in obtaining care, and lack of delay was significantly associated with G-ANC participation (χ² = 2.05, p = 0.01). This pattern suggests that structured antenatal care may contribute to more timely service utilization, potentially through improved awareness, peer support, and scheduled group visits.

Among respondents who did report delays, most described difficulty reaching the facility, followed by delays in seeking or receiving care. The type of delay was significantly associated with healthcare access (χ² = 3.21, p = 0.01), implying that both personal decision-making and health system responsiveness shape maternal care pathways.

Overall, findings indicate that while geographic and financial barriers persist, G-ANC participation may support timely care access, reducing delay risk for the majority of women. Continued efforts to address transport, cost, and social support challenges may further strengthen maternal health outcomes in similar settings.

Discussion

Most participants were young, married, and primarily housewives with low educational attainment. This aligns with Nigeria Demographic and Health Surveys (NDHS) findings, where Northern and peri-urban populations exhibit lower education levels and younger pregnancies [11–13]. Educational and socioeconomic status remain strong predictors of ANC utilization disparities, with poorer, less-educated women less likely to access ≥ 4 ANC visits [14–16]. Primigravidity predominated, and fewer than a tenth had three or more living children. Young, first-time mothers were more likely to participate in G-ANC, consistent with evidence from low-income settings showing that initial pregnancies often attract higher care uptake. Parity also appeared to influence participation, with engagement declining among women with more children, echoing prior studies linking birth order inversely to ANC attendance [17–27]. Cross-country comparisons (Ethiopia: 42.2% >4 visits [28–30]; Saudi Arabia: 41.1% ≥5 visits [31]; Egypt: 20.1% >4 visits [32]; Uganda: 67.6% ≥4 visits) should be interpreted cautiously, as differences in health system capacity, accessibility, cultural norms, and program coverage likely contribute to observed variations.

A notable majority of respondents reported pregnancy complications, chiefly infections, hemorrhage, and hypertension. Current complications were associated with ANC engagement, suggesting that adverse experiences may influence care-seeking behavior. Previous pregnancy complications were widely reported (96%), yet not significantly associated with current behavior, possibly reflecting normalization of recurrent risk within the community [33]. These findings reinforce literature on Nigeria’s persistent burden of maternal morbidity from infections, hypertensive disorders, and obstetric hemorrhage [33, 34] and underscore the potential value of structured ANC programs emphasizing early detection and management.

Service utilization and satisfaction were high: 88.4% attended 7–9 visits, and 88.4% expressed satisfaction, with 53.3% rating services as “excellent” and 34% as “better.” These satisfaction levels are consistent with Nigerian studies reporting > 90% contentment linked to empathetic provider behavior, communication, and medication availability. Active participation in learning sessions was reported by 80%, with 44.2% engaging in participatory brainstorming, 35% benefiting from lectures, and 18.7% via health-management discussions. Although learning modality was not significantly associated with outcomes, the trend toward participatory methods aligns with evidence that peer learning and empowerment are central to G-ANC mechanisms [35, 36].

Regarding delivery outcomes, 95.6% of participants delivered at healthcare facilities, reflecting a strong association between G-ANC participation and institutional delivery, though causality cannot be inferred. Positive perceptions of G-ANC’s role in improving ANC understanding and reducing maternal morbidity/mortality were prevalent (84.9% and 75.6%, respectively), and intentions to return for delivery (84%) and recommend G-ANC to others (70.2%) were significantly associated with participation. These findings suggest potential pathways, such as peer support and social learning, that may facilitate engagement and advocacy, consistent with realist synthesis perspectives on G-ANC.

Despite these positive patterns, barriers persisted. Distance to facilities (49.3%) and financial constraints (36.0%) remained key obstacles, reflecting the first and second delays described in the three delays framework. While 95.6% reported no delay in receiving care, 1.8% did, predominantly due to difficulty reaching facilities, followed by delays in seeking or receiving care. These findings emphasize that structural and socio-economic factors continue to influence maternal health access, even within structured group care programs [37–39].

In general, G-ANC in this peri-urban Nigerian context was highly acceptable and associated with increased ANC contacts, satisfaction, knowledge, and institutional delivery, highlighting its potential as a participatory model [40–44]. Mechanisms such as peer support, social learning, and empowerment likely underpin these associations. However, systemic barriers, including distance, cost, and infrastructure, persist, demonstrating that program delivery alone may not overcome broader social determinants of maternal health [20–25, 45].

Based on the findings of this study and the broader body of literature, several evidence-based recommendations can be proposed to improve maternal health outcomes in Nigeria and similar low- and middle-income country (LMIC) settings. Scaling up G-ANC across primary healthcare (PHC) networks is strongly recommended, with careful adaptations to address literacy levels, language diversity, and cultural norms in both peri-urban and rural communities. Tailoring the program to local contexts will enhance acceptability and participation, ensuring that women from diverse backgrounds can fully benefit from the model’s participatory and educational components.

To address persistent barriers to care, particularly the first and second delays identified in the study, it is crucial to integrate transportation and financial support systems into G-ANC implementation. Lessons can be drawn from successful initiatives such as Ondo State’s Abiye Safe Motherhood program, which demonstrated that community-based transport schemes and financial support mechanisms can effectively reduce access-related barriers and improve maternal health outcomes. Such interventions should be designed to be scalable and sustainable, ensuring that logistical and economic challenges do not prevent women from accessing timely antenatal services.

Community engagement and male involvement should also be strengthened to foster supportive environments for maternal health-seeking behaviors. Evidence from other Nigerian studies indicates that involving male partners and influential community members can improve ANC uptake, reinforce health education messages, and encourage adherence to recommended maternal health practices. Social mobilization strategies and community awareness campaigns can further enhance collective ownership of maternal health programs, promoting sustained engagement with G-ANC initiatives.

Health system strengthening remains a critical component of successful G-ANC scale-up. Ensuring adequate availability of trained health personnel, essential drugs, and diagnostic equipment is fundamental, as is the institutionalization of empathic communication training for healthcare workers. Moreover, enforcing policies that guarantee free maternal and antenatal services is essential to reduce financial barriers and foster trust in healthcare delivery, particularly in settings where informal payments or service gaps may otherwise limit utilization.

Finally, future research should focus on longitudinal and mixed-methods approaches to generate robust evidence on the effectiveness and cost-effectiveness of G-ANC. Incorporating control groups and follow-up assessments will allow for stronger causal inferences regarding the impact of G-ANC on maternal morbidity, mortality, and neonatal outcomes. Additionally, qualitative evaluations are necessary to explore the nuanced mechanisms, such as empowerment, peer support, and participatory learning, through which G-ANC influences maternal health outcomes across diverse cultural and social contexts. Such research will provide critical guidance for refining G-ANC models and informing policy decisions to enhance maternal health at scale.

Strengths and limitations

This study has several methodological strengths that enhance the reliability and relevance of its findings. Foremost, the substantial sample size of 450 participants drawn from multiple primary healthcare centers (PHCs) across the study area ensured broad representation and increased the generalizability of results within the peri-urban context. High fidelity to Group Antenatal Care (G-ANC) protocols was maintained throughout the study, ensuring consistency in the delivery of the intervention and allowing for accurate assessment of its implementation. Additionally, the study employed comprehensive quantitative data collection, capturing critical indicators such as service utilization, satisfaction, and perceived impact, which provided a rich dataset for examining key maternal health outcomes.

However, certain limitations should be acknowledged. The cross-sectional study design inherently restricts causal inference; while associations between G-ANC participation and outcomes were identified, the temporal or causal direction of these relationships cannot be established. The use of self-reported, interviewer-administered questionnaires introduces potential biases, including recall bias and social desirability bias, which may have led participants to overstate satisfaction or perceived benefits. Furthermore, the absence of a comparison group receiving conventional antenatal care limits the ability to attribute observed outcomes solely to G-ANC participation, as other contextual or unmeasured factors may have influenced the results.

To address these limitations, future research should adopt longitudinal designs that track maternal outcomes over time, incorporate control groups for comparative analysis, and integrate qualitative methods to explore the underlying mechanisms and contextual factors influencing program effectiveness. Such approaches would enhance the robustness of evidence on G-ANC, validate self-reported outcomes, and provide deeper insights into how participatory antenatal care models influence maternal health behaviors and outcomes across diverse settings.

Conclusion

This study provides compelling evidence that Group Antenatal Care (G-ANC) is a highly acceptable, empowering, and effective model for enhancing maternal healthcare utilization in Karu Metropolis, Nigeria. The findings demonstrate significant improvements in antenatal engagement, participant satisfaction, active learning participation, institutional delivery rates, and perceived benefits related to understanding antenatal care and reducing maternal morbidity and mortality. These positive outcomes highlight the transformative potential of G-ANC in settings where traditional one-on-one antenatal care often faces constraints related to time, staffing, and patient engagement. Importantly, the study underscores that while G-ANC enhances service delivery and patient empowerment, it is not a standalone solution. Socioeconomic and geographic barriers, such as financial constraints, long distances to health facilities, and transportation challenges continue to limit equitable access to timely and quality care. Addressing these barriers requires a holistic, multisectoral approach that combines G-ANC with broader health system reforms, including infrastructure development, financial risk protection mechanisms, and community-based transportation solutions. Furthermore, the success of G-ANC in this context suggests that with strategic scale-up, supportive policies, and consistent monitoring and evaluation, the model can be replicated across similar low- and middle-income country (LMIC) settings. Future implementation should prioritize context-specific adaptations, active stakeholder engagement, and integration with digital health tools to expand reach and impact. Ultimately, G-ANC represents a promising pathway toward achieving universal access to quality maternal health services, reducing preventable maternal and neonatal deaths, and advancing global health equity. 

Authors’ contributions

YMS, WY, and GIH conceptualized and designed the study and contributed to drafting and revising the manuscript. YMS, WY, SOA, GIH, and AIA contributed to data collection, and manuscript review, All authors participated in study design, and critically reviewed the manuscript for important intellectual content. All authors assisted with the literature review, data visualization, and preparation of initial manuscript drafts, All authors provided methodological expertise, and contributed significantly to manuscript revisions. All authors supported data acquisition and provided feedback on the manuscript drafts. All authors contributed to the manuscript structure, final proofreading, and editing for clarity and coherence; all authors have read and approved the final manuscript.

Funding

This study did not receive any specific grant from any funding institution.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to privacy considerations of the participants but are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (2013 version) as adopted by the World Medical Association. Ethical approval for the study was secured from the Health Research and Ethics Committee of the Nasarawa State Ministry of Health. Written informed consent was obtained from all participants after the study objectives were explained. Participation was voluntary, and confidentiality of respondents was strictly maintained throughout the study process.

All collected data were handled with utmost confidentiality and were used solely for research purposes. The study procedures adhered to the Nigerian Data Protection Regulation (NDPR, 2019) to ensure data privacy, security, and responsible handling of personal information. No identifying information was disclosed to third parties, and data were anonymized before analysis to maintain participant privacy throughout the research process.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.