|Year : 2020 | Volume
| Issue : 1 | Page : 42-48
Choices and determinants of delivery location among mothers attending a primary health facility in Southern Nigeria
Ofonime Effiong Johnson1, Precious Chizaram Obidike2, Miriam Uzezi Eroh2, Abasiono Augustine Okpon2, Emmanuel Imeh Bassey2, Paschal Christodiong Patrick2, Princewill Edet Ebong2, Emmanuel Ojumah2
1 Department of Community Health, University of Uyo; Department of Community Health, University of Uyo Teaching Hospital, Uyo, Nigeria
2 Department of Community Health, University of Uyo, Uyo, Nigeria
|Date of Submission||06-Oct-2019|
|Date of Acceptance||30-Nov-2019|
|Date of Web Publication||14-Jan-2020|
Dr. Ofonime Effiong Johnson
Department of Community Health, University of Uyo Teaching Hospital/University of Uyo, Uyo
Source of Support: None, Conflict of Interest: None
Background: The delivery locations of pregnant women contribute greatly to their birth outcome. The objectives of this study were to determine the choices and determinants of delivery locations among mothers attending a primary health centre (PHC) in southern Nigeria. Research Methodology: This was a descriptive cross-sectional study among mothers attending PHC, West Itam, Itu, Nigeria. Data were collected using interviewer-administered questionnaire and analysed with STATA version 12.0. Level of significance was set at 0.05. Results: A total of 185 mothers participated in the study. The mean age of respondents was 27.6 ± 5.2 years. The delivery locations of last pregnancy were health facility (64.9%), traditional birth attendant's place (23.3%), respondent's residence (6.3%) and church (5.4%). The top five reasons that influenced the choice of delivery locations were distance (45.4%), cost (34.6%), skills of healthcare workers (30.3%), drug availability (27.6%) and attitude of healthcare workers (26.5%). Utilisation of healthcare facilities for delivery increased significantly with level of education and income of respondents and spouses (P < 0.05). Conclusion: Different non-institutionalised delivery locations were utilised by some of the respondents. Factors influencing women's choices of delivery locations included distance, cost and attitude of health workers. It is recommended that pregnant women be offered free or highly subsidised healthcare services to encourage their delivery at health facilities. Healthcare providers should endeavour to develop better relationship with clients who patronise their services. Female education should also be encouraged as this would empower them to make better choices about their health services options.
Keywords: Delivery locations, determinants, mothers, Nigeria, primary health centre
|How to cite this article:|
Johnson OE, Obidike PC, Eroh MU, Okpon AA, Bassey EI, Patrick PC, Ebong PE, Ojumah E. Choices and determinants of delivery location among mothers attending a primary health facility in Southern Nigeria. Niger Postgrad Med J 2020;27:42-8
|How to cite this URL:|
Johnson OE, Obidike PC, Eroh MU, Okpon AA, Bassey EI, Patrick PC, Ebong PE, Ojumah E. Choices and determinants of delivery location among mothers attending a primary health facility in Southern Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Feb 23];27:42-8. Available from: http://www.npmj.org/text.asp?2020/27/1/42/275809
| Introduction|| |
Maternal mortality and morbidity are global public health concerns. Every minute, a woman dies from childbirth-related complications worldwide. Each year, 536,000 maternal deaths occur worldwide and Africa contributes the highest. Approximately 95% burden is recorded in sub-Saharan Africa and Asia. Maternal mortality ratios in Nigeria was 814/100,000 live births in 2015. Most maternal deaths occur as a result of complications that arise during labour, delivery and the immediate postpartum period with obstetric haemorrhage and pre-eclampsia being the main medical causes of maternal death.
The birth outcome and quality of life of women and newborn children after delivery are often dependent on the choice of location of delivery. It has been found that women who deliver in health facilities with access to skilled birth attendants have better outcome with reduced risk of maternal and neonatal morbidity and mortality compared to those who patronise other delivery locations. Sadly, more than 50% of births in developing countries are reported to take place at home. Majority of maternal and neonatal mortalities are associated with preference of delivery in places other than the hospital. Many of these deaths can be prevented with access to skilled birth attendants.,
The different delivery location options available to women in Nigeria (and other developing countries) include institutional delivery – delivery in a health facility, and non-institutional delivery – delivery at home, church, traditional birth attendant's (TBAs) home or at make shift private clinics owned by poorly trained or untrained people. Different studies have reported prevalence of non-institutional deliveries of 39%–61%.,,, Determinants of choices of childbirth locations by women have been explored by numerous studies. Factors associated with home birth among women in sub-Saharan Africa include poor access to health facilities, cost of healthcare services, attitude of healthcare workers, educational level of the women, husband's educational level, parity, lack of privacy, fear of surgery, cultural practices, rural residence, low economic status, religious beliefs and lack of female autonomy., 7, ,,,
Proximity to the health facility is an important factor that women consider in choosing where to deliver. A longer distance or travel time to the closest health facility is reportedly associated with fewer women utilising the facility. Several studies have identified long distance as a major hindrance to facility delivery.,, Furthermore, the cost of health services is another factor considered in choosing a delivery location. Up to 80% of women in a rural community in Delta State, Nigeria who chose not to use the health facility claimed that high cost of health services was a major reason for their decision. Similar pattern has been reported in other studies.,
The attitude of health workers greatly affects women's choice of birth place. Women who were satisfied with the care during antenatal clinic attendance were very much likely to deliver at the hospital compared to women who were not satisfied. Respondents in an Ethiopian study preferred TBAs over the healthcare workers as they were said to be more kind. It has also been reported that poor staff coverage of the primary health facilities makes it hard for the women to always be sure of a steady availability of health services whenever they need to in the event of the commencement of labour, and this discourages their use of health facilities.
The educational levels of women and their husbands also influence the choice of delivery location. Women with good education were more likely to access and receive healthcare services from a hospital facility than uneducated women during pregnancy. Studies have reported a higher odds of Illiterate women delivering in non-institutional birth places as compared to those with secondary and tertiary education., Studies have also shown that the use of healthcare services by pregnant women was directly proportional to the level of education of their husbands.,, Furthermore, the husband's occupational status has significant influences on the choice of location of childbirth. A study conducted in a rural settlement in Zaria, Northern Nigeria, showed that the employment status of the husband was an important factor as wives with gainfully employed husbands delivered at health facilities. Women whose husbands were jobless or manual labourers were less likely to patronise a hospital compared to women whose husbands had good jobs.
Women's place of residence was found to be a significant predictor of choice of delivery location. An urban-rural study among women in Sokoto showed that 65% delivered in the health facilities for urban group of respondents while 4.79% delivered in the health facilities for the rural group of respondents respectively. On review of the records of the Primary Health Centre (PHC) at West Itam, Itu, Nigeria, it was found that out of 4,056 women who attended antenatal care (ANC) within 1 year, only 264 (6.5%) delivered at the facility within the period. It was therefore necessary to determine the factors contributing to low patronage of the health facility for delivery despite documented clinic attendance. The objectives of this study were to determine the delivery locations available and factors that influence the choice of such locations among women attending PHC, West Itam, Itu, Nigeria
| Research Methodology|| |
This was a descriptive cross-sectional study carried out from 12th to 23rd August 2019, at the PHC, West Itam district, a semi-urban area in Itu, one of the 31 Local Government Areas of Akwa Ibom State, located in the Niger Delta region of Nigeria, with an estimated population of 127,856, comprising 65,410 males and 62,446 females. Many of the inhabitants are traders, artisans and farmers, with some in the civil service. The PHC has 17 members of staff made up of 6 nurses and 11 Community Health Extension Workers (CHEW). The facility runs child welfare clinics on Mondays, Wednesdays and Thursdays and antenatal clinics on Tuesdays and Fridays. The study population consisted of mothers attending child welfare and antenatal clinics in the PHC during the period of study with previous birth experience.
Sample size determination and selection of participants
The sample size was calculated using the Fisher's formula for descriptive studies (n = z2pq/d2), with a standard normal deviate (z) of 1.96 at 95% confidence level, P of 87.5% (prevalence of home deliveries in a previous Nigerian study), q being 12.5% (1 − p) and degree of accuracy (statistical assumption of a type 1 error rate) of 0.05. This gave a sample size of 168. Adding 10% for non-response, the total sample size was 185. All consenting mothers who brought their babies to the child welfare clinics on Mondays, Wednesdays and Thursdays and all pregnant mothers attending the antenatal clinic on Tuesdays and Fridays during the study period, were recruited into the study until the required sample size was achieved. An average of 30 mothers and 20 pregnant women attended the child welfare clinic and the antenatal clinic on each clinic day respectively. All women who were either pregnant for the first time or did not give consent were excluded from the study.
Survey instrument, data collection and analysis
The instrument of data collection was an interviewer administered structured questionnaire which was developed by the researchers in line with the study objectives. Information obtained included sociodemographic characteristics of the mothers and husbands, choice of delivery location, factors influencing the choices and knowledge of risks associated with the different delivery locations. Data were collected by 7 of the researchers on the antenatal and child welfare clinic days during the period of the study. Data collection lasted for 10 days.
The data collected were collated and analysed using STATA, (StataCorp.2011. Stata Statistical Software: Release 12. College Station, Tx: StataCorp LP). Categorical data were summarised using frequency and percentages and association tested using Chi-square or Fishers exact test. Continuous data were summarised using mean and standard deviation. Level of significance was set at 0.05.
Ethical clearance with approval number UUTH/AD/S/96/VOL.XXI/307 was obtained from the Ethical Review Committee of University of Uyo Teaching Hospital, Uyo, Nigeria on 1st August, 2019. Permission was also obtained from the authorities in charge of the PHC at the study location. Written informed consent was obtained from consenting clients after adequate information was given. Voluntariness, confidentiality and privacy were ensured.
| Results|| |
A total of 185 respondents attending the PHC at West Itam participated in the study. The mean age of the respondents was 27.6 ± 5.2 years, 156 (84.3%) had at least secondary level of education, 48 (26%) were traders, 35 (18.9%) were unemployed and 121 (65.4%) of the respondents earned <₦ 50,000 [Table 1]. One hundred and twenty (64.9%) of the respondents had their last delivery in health facilities, while 23.3% delivered in TBA homes [Figure 1]. The top five most important factors that influenced choice of delivery location among the mothers were distance 84 (45.4%), cost 64 (34.6%), skills of healthcare provider 56 (30.3%), supply of drugs 51 (27.6%) and attitude of healthcare workers 49 (26.5%) [Figure 2].
|Figure 1: Last delivery location of all respondents attending primary health centre, West Itam|
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|Figure 2: Factors affecting choice of delivery locations among respondents|
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[Table 2] shows that age, level of education and income of the respondents were significantly associated with the choice of delivery location (P < 0.05). The utilisation of the health facility increased with age, level of education and income. About half of the respondents' husbands were civil servants (51.4%), 87% completed at least secondary education, 41.6% earned <₦50,000 monthly. Level of education, occupation and income of the spouse were all statistically, significantly associated with the respondent's choice of delivery location (P < 0.05) [Table 3]. [Table 4] shows that 145 (78.4%) of the women believed the health facility to be the safest place for delivery. Twenty (10.8%) knew of women who had obstructed labour during delivery with the TBA. Thirty five (18.9%) and 29 (15.7%) of the respondents admitted knowing women who died while delivering with the TBA and at home respectively.
|Table 2: Association between sociodemographic characteristics and delivery locations of respondents|
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|Table 3: Association between sociodemographic characteristics of spouse and delivery locations of respondents|
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|Table 4: Awareness of the risks associated with different delivery locations|
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Majority of the respondents 135 (73.0%) took the decision concerning choice of delivery location. Out of these, 31.9% chose not to deliver in any health facility. A significantly higher proportion of those who delivered in the health facility (95.0%) were attended to by skilled birth attendants compared to those who delivered outside the facility (43.1%) (P < 0.001). Furthermore, a significantly higher proportion of those who delivered in the health facility attended ANC compared to those who delivered outside the health facility (P < 0.001). Interestingly, 83.1% of those who delivered outside the health facility had attended ANC. Overall, 172 (93.5%) of respondents attended ANC but almost a third of them did not deliver in a health facility [Table 5]. Among currently pregnant mothers, 87.5% were planning to deliver in a health facility, while 10.7% planned to deliver at TBA homes and for 25.0%, the decision was made by the respondents' husbands. The proposed mode of payment for 87.5% would be out of pocket [Table 6].
|Table 5: Association between events at last delivery and respondent's delivery location|
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|Table 6: Various plans towards next delivery among currently pregnant respondents (n=56)|
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| Discussion|| |
The purpose of this study was to determine the factors that influence the choice of delivery locations among women attending PHC, West Itam, Itu, Nigeria. About one third of the women (35.1%) had their last deliveries outside the health facilities. Similar studies have reported a proportion of 39%–45% of non-institutionalised deliveries among women.,,,, In the present study and two similar studies in southern Nigeria,, the most common delivery location outside the health facility was the TBA homes (23.3%, 11.9% and 45% respectively), which is in contrast with a study done in Ilesha, Nigeria where 35.4% of the deliveries took place in churches, making that the most common non-institutionalised birth location. This is possibly because churches with birth locations are more common in the south western part of Nigeria compared to the south east and south-south. Non-institutionalised deliveries deny women access to skilled birth attendance with adequate infrastructure, equipment and effective referral system, thus possibly increasing chances of birth complications in the course of delivery.
Contrary to expectation, ANC does not necessarily translate to delivery in healthcare facilities. Instead, when a woman has been told that her pregnancy is 'normal' during ANC, she tends to believe that she would be able to deliver outside the health facility without incident. In Nigeria, the Nigeria Demographic and Health Survey 2018 report records 67% ANC attendance but health facility delivery was only 39%. In a study in Ghana, out of 98.8% who attended ANC, the proportion of women who delivered in a health facility was 61.9%. This is similar to the present study, where 93.5% of respondent attended ANC but about a third of them did not deliver in a health facility.
The top five reasons that influenced the respondents' choices of delivery location in the present study were distance, cost, skills of healthcare provider, supply of drugs and attitude of healthcare workers. Distance is a key consideration as proximity is of advantage since the women would desire to reach the location as quickly as possible, especially as some may not have a personal means of transportation. A similar finding was reported in a study done in Ethiopia where 50% of the women chose their delivery locations based on distance from their homes. In another study done in Kano State, Nigeria, of the 74.1% that delivered at home, 12.2% cited distance as the major determinant of their delivery location.
Another key reason that women often consider in choosing where to deliver is the cost of delivery in the location. About a third of the respondents in the present study reported that non institutionalised locations were often considered because they were cheaper than the health facilities. This is not surprising as majority of them had to make out of pocket payment for health services considering that majority were low income earners. In a similar study, 80% of women in a rural community in Delta State, Nigeria cited high cost as a major reason for their decision not to use the Health facility. There is therefore a serious need for the government to subsidise deliveries or make it totally free to encourage facility births and a reduction in maternal mortality.
In addition, the characteristics of healthcare services, particularly staff attitude affected women's choice of birth place in the present study. Many of them expressed preference for other delivery locations such as TBA homes due to their friendly attitude. This was despite the fact that about a fifth of them admitted to knowing women who died while delivering with the TBA. The birth process is accompanied by a lot of pains. Women therefore naturally would prefer birth attendants with a lot of empathy. Negative attitude of healthcare service providers, poor relationships between patients and doctors and rude and unfriendly attitude of nurses were major determinants of women's preference for other delivery places in other studies., In a Northern Nigeria study, of the 74.1% of women that did not complete their ANC and later gave birth with the TBAs, 13.7% did so due to the attitude of the healthcare workers. A reorientation of health workers towards having more friendly dispositions towards their clients, especially women in labour is therefore very needful.
Though majority of the respondents made the decision about where to deliver, the husbands determined the location for a quarter of the respondents. In a Nigerian study, 12% of women were not allowed by their husbands to decide on their delivery location. This calls for male involvement during ANC in order for them to be adequately informed about the attendant risks in deliveries outside the health facilities.
Delivery at health facilities among respondents in the present study increased with income and level of education. A study done in Northern Nigeria showed that the odds of home delivery was 3.88 times higher in women with non-formal education than those with formal education. This supports findings of 2013 and 2018 Nigerian Demographic Health Surveys which showed that women with higher levels of educational achievements were more likely to deliver at health facilities than women with little or no education., Efforts should therefore be made to encourage female education as this has a positive effect on the uptake of health services by that population.
The husband's level of education, employment status and income were all significantly associated with respondent's delivery in a health facility in the present study. This stands to reason as the educated ones were more likely to appreciate the benefits of facility delivery. A study done in Sweden showed that majority of educated women and about 70% of women whose husbands were educated were aware of the possible complications associated with delivering with a TBA. An educated husband would also possibly be more gainfully employed, thus earning higher income than the uneducated. A couple's level of education therefore plays an important role in their choice of delivery location.
| Conclusion|| |
Patronage of TBA homes was a common practice among women in the study population. The utilisation of healthcare facilities for delivery increased with level of education and income. Factors that influenced women's choices of delivery location included distance, cost and attitude of healthcare workers.
It is recommended that pregnant women be offered free or highly subsidised healthcare services to improve their delivery at health facilities and significantly reduce maternal and child mortality rates. Healthcare providers should endeavour to develop better relationship with clients who patronise their services. Female education should also be encouraged as this would increase their empowerment to make better choices about their health services options.
Limitation of the study
The study was limited by recall bias as some of the respondents were not able to remember the circumstances surrounding the events that happened several months previously. There was also self-report bias in that the researchers relied on the respondents' responses which could not be verified.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]