|Year : 2019 | Volume
| Issue : 2 | Page : 68-75
Determinants of choice of place of delivery among women attending two referral hospitals in Kano North-West Nigeria
Ogonna N. O Nwankwo1, Oluchukwu Emmanuel Ani2, Michael Akpoke3, Emmanuel Ajuluchukwu Ugwa4
1 Department of Community Medicine, University of Calabar, Calabar, Cross River State, Nigeria
2 Department of Community Medicine, Bayero University Kano, Kano State, Nigeria
3 Department of Paediatrics, University of Sierra Leone Teaching Hospital Complex, Freetown, Sierra Leone
4 Department of Obstetrics and Gynaecology, Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria
|Date of Web Publication||31-Jul-2019|
Dr. Emmanuel Ajuluchukwu Ugwa
Department of Obstetrics and Gynaecology, Federal Medical Centre, Birnin Kudu, Jigawa State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Women are often unable to choose for themselves when, where, and from whom to seek care. This study was undertaken to determine factors that influence a woman's choice of place of delivery among women attending immunization clinics in two referral hospitals in Kano, Nigeria. Materials and Methods: A hospital-based cross-sectional descriptive study conducted among 314 women who delivered in Kano, Nigeria. Stratified random sampling was done. Pretested, interviewer-administered questionnaires were used to obtain responses about sociodemographic characteristics, choice of place of delivery, and factors that influenced their choice of place of delivery. Ethical approval was obtained from an ethical committee. Women who gave birth within the past 12 months and gave informed consent were recruited. The data were analyzed using SPSS statistical software version 22. Results: About 218 (69.4%) women had their previous delivery in the health facility, whereas 96 (30.6%) had theirs outside the health facilities. The level of satisfaction in health facility care was also high. For those who had their deliveries outside the health facility, 37 (38.5%) of the deliveries were monitored by a nurse/midwife. The respondents level of education (P ≤ 0.001), spouse level of education (P < 0.001), spouse occupation (P ≤ 0.015), human influence (P = 0.025), and total cost of each visit (P = 0.010) were associated with the choice of place of delivery; however, at multivariate logistic regression, only human influence and respondents level of education were determinants of the choice of place of delivery. Conclusion: Most of the respondents had their previous deliveries in the health facilities and had a high level of satisfaction with the health facilities where they delivered compared to other studies. Utilization of the health facilities for childbirth may increase if there is involvement of relations, especially husbands and mothers and if the clients' level of education is improved.
Keywords: Choice, delivery, determinant, northwest Nigeria, referral hospital
|How to cite this article:|
Nwankwo ON, Ani OE, Akpoke M, Ugwa EA. Determinants of choice of place of delivery among women attending two referral hospitals in Kano North-West Nigeria. Niger Med J 2019;60:68-75
|How to cite this URL:|
Nwankwo ON, Ani OE, Akpoke M, Ugwa EA. Determinants of choice of place of delivery among women attending two referral hospitals in Kano North-West Nigeria. Niger Med J [serial online] 2019 [cited 2020 Nov 27];60:68-75. Available from: https://www.nigeriamedj.com/text.asp?2019/60/2/68/263835
| Introduction|| |
Evidence from several surveys and studies have shown poor utilization of antenatal care and facility-based delivery by women in Nigeria and other sub-Saharan African regions.,,,, Poor maternal and newborn metrics in these regions have been associated with poor use of health facilities.,,,,, Women are often unable to decide for themselves when, where and from whom to seek care. They often end up being delivered by unskilled persons.
Factors including unavailability of the services, inadequate number of skilled personnel, geographical inaccessibility, and poor quality of care have been identified as a barrier to utilization of health facility for delivey. Low maternal education, unemployment among fathers, first pregnancies at <18 years of age increase the likelihood of home delivery. Distance has also been reported as an important determinant of the place of delivery.
One study showed a significant association between caste, education of mothers, education of spouse, occupation of spouse, per capita income, time to reach the nearest health center, parity, previous place of delivery, number of antenatal visit, knowledge about place of delivery, planned place of delivery, and place of delivery.
Understanding the determinants of delivery in a facility is important for program and policy planning. This study was undertaken to determine factors that influence a woman's choice of place of delivery among women attending immunization clinics in two referral hospitals in Kano, North-West, Nigeria.
| Materials and Methods|| |
Study setting and design
A hospital-based cross-sectional descriptive study conducted at immunization clinics of Murtala Mohammed Specialist Hospital and Muhammad Abdullahi Wase Specialist Hospitals in Kano following delivery. Ethical approval and informed consent were obtained. Women who gave birth within the last 12 months and were willing to give consent were recruited.
Kano State is located in North-West Nigeria. It is the second largest industrial center after Lagos State in Nigeria and the largest in Northern Nigeria with textile, tanning, footwear, cosmetics, plastics, enamelware, pharmaceuticals, ceramics, furniture, and other industries. With a population of 9,401,288 and area of 20,131 km, Kano is one of the largest cities in Nigeria consisting of 44 local government areas. Murtala Mohammed Specialist Hospital and Muhammad Abdullahi Wase Specialist Hospitals are two large State-owned referral hospitals located at the metropolis.
Sample size determination and sampling procedures
A single formula as n = z2 pq/d2, was used to estimate the sample size. The following assumptions were made while calculating the sample size. The degree of precision or margin of error (d) chosen to be 0.05 with the reliability coefficient (z) of 1.96% certainly (z = 1.96). The proportion of women who indicated interest to deliver in the facility in a recent survey in Kano was 26.6%. Therefore, the proportion of women who indicated interest to deliver in the facility, P = 0.266 and q = 0.734. This gave a sample size of 300. We added 5% to account for attrition and nonresponse to obtain a sample size of 315. Women of childbearing age (15–49 years) who gave birth within the past 2 years and lived in Kano for a minimum of 1 year before the study and willing to give consent were included in the study. Since the population of the district is heterogeneous, stratified random sampling was used to minimize bias and increase reliability. The two district hospitals were designated as strata since they differ with respect of locations within the metropolis, population served and socioeconomic perspectives. Subjects per stratum were randomly selected and the number per stratum was determined by the percentage contribution of each hospital to the population in general and to the expected number of deliveries. Normally, the population around Murtala Mohammed Specialist Hospital is dense and number of deliveries higher compared to Muhammad Abdullahi Wase Specialist Hospital. Therefore, a total of 201 (63.8%) respondents were assigned for Murtala Mohammed Specialist Hospital and 114 (36.2%) was assigned to Muhammad Abdullahi Wase Specialist Hospital.
Data collection tools and procedure
Data were collected using a pretested and structured questionnaire administered by face to face interviews. The questionnaire was adapted from other similar studies., The questionnaire was originally developed in English; but back-translated to the respondents in their various local dialects. The questionnaire was pretested for clarity and content validity. The questionnaire consists of sociodemographic characteristics (age, ethnicity, religion, educational status, and occupational status and obstetric history including women's place of delivery for their last childbirth, women's past obstetrical history and factors that influence their choice of delivery. Data were collected by trained research assistants under the supervision of the study team.
Data were cleaned and analyzed using SPSS version 22.0 (SPSS Inc., Chicago IL, USA). Descriptive statistics were carried out using frequencies, percentages, means and standard deviations while bivariate analysis was carried out in assessing for associations between independent variables and choice of place of delivery. Logistic regressions were also used to identify the predictors of choice of delivery among women. This was carried out by putting the independent variables that were statistically significant at P < 0.05 the bivariate analysis level into the logistic regression model. The statistical test of significance was set at P < 0.05
| Results|| |
A total of 314 study participants completed the study, giving a response rate of 99.7%. The ages of the respondents ranged from 15 to 49 years with a large proportion of the respondents, 125 (39.8%) falling into the 20–24 years' age group. The mean age ± standard deviations of respondents were 26.3 ± 5.8 years. Most of the respondents, 306 (97.5%) were married. [Table 1], [Table 2], [Table 3]. About 218 (69.4%) had their previous delivery in the health facility and 96 (30.6%) had theirs outside the health facilities. For those who had their deliveries outside the hospital, 37 (38.5%) of the deliveries were monitored by a nurse/midwife and 26 (27.1%) monitored by a traditional birth attendant (TBA) [Table 4] and [Table 5]. The respondents showed a high level of satisfaction with the care they received from the health facility mainly due to good care [Table 6]. Although the respondents level of education (P ≤ 0.001), spouse level of education (P < 0.001), spouse occupation (P ≤ 0.015), human influence (P = 0.025) and total cost of each visit (P = 0.010) were associated with choice of place of delivery [Table 7], [Table 8], [Table 9], however at multivariate logistic regression only human influence and respondents level of education were determinants of the choice of place of delivery [Table 10]. The respondents with vocational training, secondary and tertiary education were more likely to use health facility for delivery compared to those with informal or no level of education. Thus, people with tertiary education were approximately 99% less likely not to have their delivery outside the health facility compared to people with no formal level of education (odds ratio 0.078: confidence interval 0.011–0.567; P = 0.012).
|Table 5: Factors that influenced respondent's satisfaction with management of previous delivery|
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|Table 6: Reasons for respondent's level of satisfaction with care provided in previous delivery|
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|Table 7: Factors influencing respondents' utilization of health care services for delivery|
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|Table 9: Other factors influencing respondents' choice of place of delivery|
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|Table 10: Multivariate logistic regression of determinants of nonuse of health facility for delivery|
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| Discussion|| |
Most of the respondents are between 20 and 24 years and considered youthful. Pregnancy and delivery among women at this age may be associated with complications such as anemia, preeclampsia, prolonged labor, etc., As shown in the present study, northern Nigeria women who are predominantly Hausa and Muslim go into pregnancy and labor at relatively younger ages,, compared to women in the Southern part who are relatively older during pregnancy and labor., A previous study has also shown that women who get involved in their first pregnancy at 18 years or below are unlikely to use the health facility for their delivery.
About 218 (69.4%) had their previous delivery in the health facility. This is higher than the national average and finding by Shehu et al. in Sokoto who reported that that proportion of women who delivered in health facilities was 65% and 4.7% in the urban and rural groups, respectively., Idris et al. in a study done in Zaria also showed that as much as 70% of women in a sub-urban area did not have health facility delivery but were delivered of their babies at home. Very poor utilization of health facilities even among women who had ANC at a tertiary hospital has also been reported in Northern Nigeria.,
The level of satisfaction in health facility care in this study was high. Satisfaction is mostly related to good care and dissatisfaction is mostly due to poor care, attitude of healthcare workers and lack of privacy. Women's experiences of disrespect during facility-based childbirth is recognized as important determinants of quality of care, as well as women's and family's choices about where to give birth and of their overall experience in major phases of their lives. Health providers' poor attitude or lack of privacy may be disrespectful and an indicator of poor quality of care. Low levels of dissatisfaction with service quality as a result of disrespect and abuse of women have been reported in various setting and are responsible for significant number of deliveries in other places other than the health facilities.,,,,
The authors found that for those who had their deliveries outside the health facility, most of the deliveries were monitored by a nurse/midwife and this was followed by TBAs. This is contrary to a previous studies that health facility deliveries are more likely to be attended to by a doctor or nurse/midwife, whereas home deliveries are likely to be attended to by a TBA., This may be related to various community enlightenment efforts by development partners and regular home visits by healthcare workers. It is encouraging that even where facility-base delivery is poor, the use of skilled birth attendants should be encouraged.
Most of the women stated that the influence of their husbands' and mothers determined their choice of place of delivery. The respondent's level of education was also a determinant of the choice of place of delivery. Other factors such as quality of care issues including disrespect, cost of services and transportation were also mentioned. Previous studies have similarly reported health care quality,, cost of care,, cost of transportation, husbands' decision labour onset at night as predictors of delivery at health facilities as women are likely to utilize delivery services in health facilities if quality of care is improved, if they can afford the financial cost of care, have readily available and affordable transportation, if their husbands are positively involved in their healthcare decision-making and if health workers including doctors are readily available to attend to women who start labor at night.
Most of the respondents had their previous deliveries in the health facilities and had a high level of satisfaction with the health facilities where they delivered compared to other studies. Factors that influenced the use of health facilities including cost, the attitude of health-care workers and influence of relations, etc., are similar to those reported in previous studies.
| Conclusion|| |
The utilization of health facilities for childbirth may increase if there is involvement of relations, especially husbands and mothers and if the clients' level of education is improved.
The study limitation is that a qualitative method including focus group discussions and in-depth-interviews with users and nonusers of health facilities, the health workers, spouses and relatives of the clients will better reveal barriers and facilitators of choice of health facilities for delivery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fagbamigbe AF, Idemudia ES. Barriers to antenatal care use in Nigeria: Evidences from non-users and implications for maternal health programming. BMC Pregnancy Childbirth 2015;15:95.
Diamond-Smith N, Sudhinaraset M. Drivers of facility deliveries in Africa and Asia: Regional analyses using the demographic and health surveys. Reprod Health 2015;12:6.
Kitui J, Lewis S, Davey G. Factors influencing place of delivery for women in Kenya: An analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy Childbirth 2013;13:40.
Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: A qualitative evidence synthesis. Reprod Health 2014;11:71.
Adewuyi EO, Zhao Y, Auta A, Lamichhane R. Prevalence and factors associated with non-utilization of healthcare facility for childbirth in rural and urban Nigeria: Analysis of a national population-based survey. Scand J Public Health 2017;45:675-82.
Doctor HV, Bairagi R, Findley SE, Helleringer S. Northern Nigeria maternal, newborn and child health programme: Selected analyses from population-based baseline survey. Open Demogr J 2011;4:11-21.
Ajayi IO, Osakinle DC. Socio demographic factors determining the adequacy of antenatal care among pregnant women visiting ekiti state primary health centers. Online J Health Allied Sci 2013;12:1-6.
Belay A, Sendo E. Factors determining choice of delivery place among women of child bearing age in Dega Damot district, North West of Ethiopia: A community based cross- sectional study. BMC Pregnancy Childbirth 2016;16:229.
Moyer CA, Dako-Gyeke P, Adanu RM. Facility-based delivery and maternal and early neonatal mortality in sub-Saharan Africa: A regional review of the literature. Afr J Reprod Health 2013;17:30-43.
Harvey SA, Blandón YC, McCaw-Binns A, Sandino I, Urbina L, Rodríguez C, et al.
Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bull World Health Organ 2007;85:783-90.
National Population Commission [Nigeria] and ICF International. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International; 2014.
Jane TB, Karen H, Robert JM, Marcia AA. Access, quality of care and medical barriers in family planning programmes. Int Fam Planning Perspect 1995;21:64-9.
Idris SH, Gwarzo UM, Shehu AU. Determinants of place of delivery among women in a semi-urban settlement in Zaria, Northern Nigeria. Ann Afr Med 2006;5:68-72.
Fisseha G, Berhane Y, Worku A, Terefe W. Distance from health facility and mothers' perception of quality related to skilled delivery service utilization in Northern Ethiopia. Int J Womens Health 2017;9:749-56.
Dhakal P, Shrestha M, Baral D, Pathak S. Factors affecting the place of delivery among mothers residing in Jhorahat VDC, Morang, Nepal. Int J Community Based Nurs Midwifery 2018;6:2-11.
Abubakar S, Adamu D, Hamza R, Galadima JB. Determinants of home delivery among women attending antenatal care in Bagwai town, Kano Nigeria. Afr J Reprod Health 2017;21:73-9.
Teferra AS, Alemu FM, Woldeyohannes SM. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela district, North West of Ethiopia: A community-based cross sectional study. BMC Pregnancy Childbirth 2012;12:74.
Anyait A, Mukanga D, Oundo GB, Nuwaha F. Predictors for health facility delivery in Busia district of Uganda: A cross sectional study. BMC Pregnancy Childbirth 2012;12:132.
Mekonnen Y, Mekonnen A. Factors influencing the use of maternal healthcare services in Ethiopia. J Health Popul Nutr 2003;21:374-82.
Nduka I, Nduka EC. Determinants of noninstitutional deliveries in an urban community in Nigeria. J Med Investig Pract 2014;9:102-7. [Full text]
Shehu CE, Ibrahim MT, Oche MO, Nwobodo EI. Determinants of place of delivery: A comparison between an urban and a rural community in Nigeria. J Public Health Epidemiol 2016;8:91-101.
National Population Commission [Nigeria] and ICF International. Nigeria Demographic and Health Survey 2013. Rockville, Maryland, USA: National Population Commission and ICF International; 2013.
Idris SH, Gwarzo UMD, Shehu AU. Determinants of place of delivery among women in a semi-urban settlement in Zaria, Northern Nigeria. Ann Afr Med 2006;5:68-72.
Ekele BA, Tunau KA. Place of delivery among women who had antenatal care in a teaching hospital. Acta Obstet Gynecol Scand 2007;86:627-30.
Idris SH, Sambo MN, Ibrahim MS. Barriers to utilisation of maternal health services in a semi-urban community in Northern Nigeria: The clients' perspective. Niger Med J 2013;54:27-32.
] [Full text]
Abuya T, Warren CE, Miller N, Njuki R, Ndwiga C, Maranga A, et al
. Exploring the prevalence of disrespect and abuse during childbirth in Kenya PLoS One 2015;10:e0123606.eCollection 2015.
Sando D, Ratcliffe H, McDonald K, Spiegelman D, Lyatuu G, Mwanyika-Sando M, et al.
The prevalence of disrespect and abuse during facility-based childbirth in urban Tanzania. BMC Pregnancy Childbirth 2016;16:236.
Moore BM, Alex-Hart BA, George IO. Utilization of health care services by pregnant mothers during delivery: A community based study in Nigeria. East Afr J Public Health 2011;8:49-51.
Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynaecol Obstet 2015;128:110-3.
Biweta M. Factors influencing women's choice of place of delivery in urban and Peri urban areas of Gondar town, North West of Ethiopia. Obstet Gynecol Int J 2015;2:43. [DOI: 10.15406/ogij. 2015.02.00043].
Wilson JB, Collison AH, Richardson D, Kwofie G, Senah KA, Tinkorang EK, et al.
The maternity waiting home concept: The Nsawam, Ghana experience. The Accra PMM team. Int J Gynaecol Obstet 1997;59 Suppl 2:S165-72.
Dickson KS, Adde KS, Amu H. What influences where they give birth? Determinants of place of delivery among women in rural Ghana. Int J Reprod Med 2016;2016:7203980.
Awoyemi TT, Obayelu OA, Opaluwa HI. Effect of distance on utilization of health care services in rural Kogi state, Nigeria. J Hum Ecol 2011;35:1-9.
Kifle MM, Kesete HF, Gaim HT, Angosom GS, Araya MB. Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea. J Health Popul Nutr 2018;37:22.
Egharevba J, Pharr J, van Wyk B, Ezeanolue E. Factors influencing the choice of child delivery location among women attending antenatal care services and immunization clinic in Southeastern Nigeria. Int J MCH AIDS 2017;6:82-92.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]