This survey showed a low rate of ITN ownership, with only 29% of pregnant women reporting that they owned bednets. After controlling for other variables, whether or not a pregnant woman owns a bed depended greatly on three explanatory variables. Women who register at antenatal clinics are more likely to own bednets. This may be the result of free or subsidised distribution of bednets to pregnant women at such facilities. The finding that women in rural areas are more likely to own bednets may reflect the successful penetration of the massive community level distribution campaigns in rural areas. This is supported by the finding that the proportions of pregnant women who own bednets are higher in predominantly rural geopolitical zones including North West and North East than the highly urbanised South West. But by far the explanatory variable with the best predictive power on ITN ownership is knowledge that ITNs prevent against malaria. Pregnant women who knew this were nearly four times as likely to own bednets compared with those who did not. It is important to note that the educational level of pregnant women was not related to ITN ownership.
It is important to note that only 25% of pregnant women who owned ITNs actually slept under one the night before the survey. While this proportion is far higher than the 7.5% for the entire sample, it shows that ownership of ITN does not necessarily translate to use. The low rate of use of ITNs by pregnant women (7.5%) is far below global and national coverage targets. This rate is a marginal improvement over results of earlier surveys with ITN utilizations rates among pregnant women of 1.3% and 2.9% in 2003 and 2006 respectively [10
]. The 2008 Nigerian Demographic and Health Survey also showed ITN utilization rate below 10%, further corroborating recent observations that ITN utilization in Nigeria has remained consistently low [13
]. The use of ITN in many malaria endemic of sub-Saharan Africa has remained generally low as shown by a recent synthesis of national data sets from several countries [15
Our study explored bednet use among pregnant women who owned bednets. This was necessary given that several studies have shown that within households that owned ITNs, several under-five children and pregnant women did not sleep under them [13
]. In one report, as much as 55% of children in households that owned ITN did not sleep under ITN [16
]. Within-country and between-country analysis of data on net ownership and use from selected sub-Saharan African countries show wide gaps between ITN ownership and use.
Our study has identified several determinants of the use of ITNs by pregnant women. Several factors influencing ITN utilization in pregnancy have also been identified by other Nigerian authors. These include education, place of residence (locality) and access to antenatal care services [27
]. Other studies have shown that educational level positively influences care-seeking behaviour. A study of pregnant Ethiopian women showed that higher educational attainment and residence in urban location were significant predictors of ITN use in pregnancy [30
]. Our study however showed no significant influence of educational attainment on ITN at both bivariate and multivariate levels suggesting the likely dominance of yet unclear, socio-cultural covariates of education in our setting. Residence in urban areas was, however, confirmed as a predictor of ITN use in our study.
Our study identified two key knowledge-based predictors of ITN use in pregnancy among women who own bednets. Pregnant women who knew that ITNs prevent against malaria were three times more likely to use bednets compared with those who did not. Similarly women who held no misconceptions about malaria prevention were more likely to use ITNs.
In our study ITN use is lagging behind ownership by quite a wide margin. With the recent massive distribution of ITNs in Nigeria, access is expected to invariably go up and may attain the national target but the extent to which this would improve utilization is being cautiously watched. As has been shown in this study, it is widely acknowledged that increase in ITN access (i.e. household ownership) does not necessarily translate to commensurate increase in utilization. It has been hypothesized that the gap between ITN access and utilization would be reduced significantly only when access at the household levels reaches or exceeds one ITN for two persons [26
]. This underscores the need to increase the number of ITNs available to users in a given household. This seems to suggest that the current mass distribution of ITNs may not necessarily lead to use unless it is accompanied with behaviour change interventions that address the community level perceptions, misconceptions and positively position ITN as an effective prevention device to prevent malaria.
The link between personal risk perception and risk-reduction behaviour has been well researched in health promotion [31
]. The perception of risk may play a significant role in the decisions of individuals to use ITNs [33
]. At the bivariate level, it was found that pregnant women who knew about the specific risks of malaria in pregnancy (such as anaemia, low birth weight, abortion) were more likely to use ITNs than those who did not. Similarly pregnant women who perceived malaria in pregnancy to be harmful were more likely to use ITNs compared with those who did not perceive it to be harmful. Pregnant women who do not see themselves or their unborn babies at risk for malaria, are less likely to use preventive devices such as ITNs, even if they possess them. For both pregnant women who own ITNs and those who do not, the knowledge that malaria may be harmful to the outcome of the pregnancy is a significant predictor of ITN use. Health promotion programmes should consider including messages that ask pregnant women to consider actual risk reduction accruable from using ITNs to protect her unborn child even if there are potential inconveniences for the woman herself.
It is important to note some limitations of this paper. Given that ITNs were distributed free in the study states, the study did not obtain information on how ITNs were acquired or the cost, factors which may affect ITN ownership in different circumstances. Also the study did not explore the physical attributes of ITNs in explaining user preferences and the potential influence on consistent ITN use. Since women will use bednets only when they owned one, we limited our study to the 21, out of 36 states, where there are current efforts at mass distribution of bednets; hence the findings may not necessarily apply to the whole country.