Factors Influencing Women’s Choice Of Place Of Delivery In Asaba LGA, Delta State
Although 92% of women receive antenatal care at least once during pregnancy, a suitable place of delivery assists only 44% of mothers during childbirth (KDHS, 2008). Therefore, the purpose of this study was to investigate the factors influencing the choice of place of delivery in Asaba LGA, Delta State. The study objectives were to determine the influence of demographic factors, socio cultural factors and economic factors on choice of place of delivery among women in Asaba LGA, Delta State. The study was conducted in May and June, 2019. It adopted a descriptive survey design and the eligible respondents were women of childbearing age. With the help of two research assistants, the researcher managed to visit four locations in Asaba LGA and Cluster sampling method was used to identify participants for the study. A total of 378 women from Asaba LGA were to participate in the study but only 373 participated giving a response rate of 98%. Two focus groups discussion were also conducted for the purpose of the study. Chi square test was used to establish the association between the independent variables and place of delivery. Statistical Package for Social Sciences (SPSS) version 17 was used for data analysis. The study shows that 67% of women delivered at hospital, 27.6% of births occurred at home without the help of a skilled birth attendant and only 4.8% of the women were attended by TBAs during delivery. Other than demographic, social cultural and economic factors that influence choice of place of delivery, other key factors influencing home delivery included less or no antenatal visits and unexpected labour. From the study there has been an increase in hospital deliveries though a significant number of mothers are still giving birth without the assistance of skilled birth attendants. To ensure that hospital deliveries are increased it was therefore recommended that advocacy to all women of child bearing age on the importance of hospital deliveries by the Ministry of Health, Ngo’s and community based organizations should be done. Involvement of husbands as key decision makers in the choice of place of delivery during antenatal clinic visits could be one of the best strategies in reduction of home deliveries. During antenatal clinic visits mothers should also be educated on issues like signs of labour and expected dates of delivery as a step to reduce home deliveries. Health workers should also strengthen the concept of focused antenatal care where mothers are sensitized on how to handle the issue of giving birth and also increase the coverage of antenatal care by reaching out to women at the community level through outreach programmes that are geared towards creating awareness that antenatal clinic visits are important for them when they are expectant.
1.1 Background to the Study
Increasing women’s access to quality skilled attendant has become a focus of global efforts to realize the right of every woman to the best possible healthcare during pregnancy and childbirth (UNFPA, 2010). Several authors have postulate that skilled attendants during labour, delivery and in the early postpartum period can prevent up to 75% or more of maternal deaths (Harvey, 2004 et al; Koblinsky, Heichelheim 1999).
Use of a skilled attendant (doctor, nurse, or midwife) at birth is one of the recognized indicators for measuring progress towards the Millennium Development Goal 5, that is, reduction of maternal mortality ratio. Improving women’s health is the fifth Millennium Development Goal as adopted by heads of states in September 2000. The agreed target is to reduce, by 2019, maternal mortality in developing countries by 75% of the 1990 figure. (MDG)
Despite various national and international efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth the majority equally divided between Africa and Asia (Ronsmans, 2006). According to (Kowalewski, 2000) less than 1% of the pregnancy-related deaths occur in the more developed parts of the world, making maternal mortality the health indicator showing the greatest disparity between developing and developed countries. Despite the enhanced focus and awareness over the past decades, the situation in the poorest countries has not improved, and maternal mortality reduction is one of the explicit health millennium development goals.
Since the second half of the 20th century, the majority of births in the western world have taken place in hospital. Medicalisation of childbirth is a central feature in Western societies (Johanson, 2002). The majority of women living in high and middle-income countries have given birth in hospitals since the middle of the 20th century. However, there are regions where home birth is considered part of normal practice. The most cited case is The Netherlands where planned home birth is supported by the official healthcare system. Here, planned home birth is considered an appropriate choice for a woman of low risk and approximately 30% of all births take place at home (Hendrix 2009).
A significant proportion of mothers in developing countries still deliver at home unattended by skilled health workers (Montagu D, Yamey G, Visconti A, Harding A, Yoong J 2011). In diverse contexts, individual factors including maternal age, parity, education and marital status, household factors including family size, household wealth, and community factors including socioeconomic status, community health infrastructure, region, rural/urban residence, available health facilities, and distance to health facilities determine place of delivery and these factors interacting diverse ways in each context to determine place of delivery. In developing countries, pregnancy and childbirth are the leading causes of disability and death among women of reproductive age.
Indeed, the majority of maternal deaths occur either during or shortly after delivery. According to United Nations Children Fund (UNICEF 2009), pregnancy and childbirth related complications claim lives of at least 585,000 women every year in developing world. Pregnancy related problems include anemia, bleeding, infection, damage of the uterus, obstructed labor and abortion. Nearly all maternal deaths in developing countries occur among the vulnerable and disadvantaged population groups and yet most of these causes are preventable. Although the main causes of maternal mortality are well known and the knowledge as well as appropriate technology to reduce it has been available, maternal health problems are still highly prevalent in most African societies.
Statistics by (WHO 2010) found that 92% of women receive antenatal care from a trained health worker but when it comes to delivery time, most of them do not deliver at health units, but instead deliver elsewhere. It was estimated that about 15% of deliveries have complications that require skilled medical intervention. Yet only 53% of deliveries in developing countries take place with the assistance of a skilled birth attendant compared to 99% in developed countries. In resource-poor settings, home delivery is usually the cheapest option, but is associated with attendant risks of infection and lack of available equipment should complications occur. (Thind A. et al, 2008).
According to (Hogan, 2008), Ethiopia is among the top six high burden countries in which half of global maternal deaths occur, with an estimated maternal mortality ratio of 470 per 100, 000 live births. The most recent Ethiopian Demographic and Health Survey (EDHS 2011), very few mothers (34%) make at least one antenatal visit and even less receive delivery care from skilled birth attendants. It reports 28% of births were assisted by a traditional birth attendant (TBA) and 57 percent of births were assisted by a relative, or some other person.
In Nigeria, maternal mortality rate has not reduced over recent years, and may even have increased from an estimated 380/100000 live births in 1990 to 530/100000 live births in 2008. Although a number of factors may have contributed to this, including improved identification of maternal deaths, health facility delivery remained low at44% and 42.6% in the early 1990s and in 2008 respectively. Recent evidence on determinants of place of delivery in Nigerian utilizing a nationally representative data and controlling for all factors is lacking, yet understanding the influences on place of delivery in Nigeria is crucial to identifying key priority areas for policy and practice to increase the prevalence of skilled assisted deliveries(KDHS 2008).
Statistics by KDHS 2008 indicate that, 43 percent of births in Nigeria are delivered in a health facility, while 56 percent of births take place at home. Traditional birth attendants continue to play a vital role in delivery, assisting with 28 percent of births (the same percentage as are assisted by nurses and midwives). Relatives and friends assist with 21 percent of births, and for 7 percent of births, mothers do not receive any form of assistance. Increasing the percentage of babies that are delivered in health facilities is an important factor in reducing the health risks to both the mother and the baby. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infection that can cause morbidity and mortality to either the mother or the baby (KDHS 2008).
Home deliveries in Kaloleni and Rabai LGAs of Kilifi State accounted for 65% of child birth by 2012 and there is not enough information in Kaloleni and Rabai to establish why these mothers still deliver at home despite concerted effort by the government and other stakeholders to encourage mother to deliver in health facilities (Mang’ong’o, 2013).
Delta State (formely Delta LGA) is a State in the former Eastern province. It has a population of 884,527 (KNBS, 2009). The State has 7 LGA hospitals, 21 health centers, 113 dispensaries and 11 private clinics. Most of the public health institutions lack sufficient drugs, equipment, transport and health personnel. The bed capacity in the State stands at 616 and doctor population ratio is 1:22,712 which is below the accepted standards. This means the population is underserved in terms of health facilities. The average household distance to health facility is six Kilometres which is way below the national recommended distance of four Kilometers (Delta State Integrated Development Plan, 2013).
1.2 Statement of the Problem
Basing on the fact that various efforts have been put in place by the Government of Nigeria, through free maternity services to increase the percentage of mothers who deliver from the health facility under the assistance of a skilled health worker, the majority of mothers still deliver at home without skilled birth attendants. Statistics by the LGA Health information System (DHIS) indicate that only 36% of births in Mbooni LGA are attended by a skilled birth attendant. This is way too far the targets set at the International Conference on Population and Development(ICPD) whose goal is to have more than 80% of deliveries assisted by skilled attendants globally by 2005, 85% by 2010 and 90% by 2019 (UNFPA 2010).
Home deliveries are poorly managed and inadequate care is offered during the critical hours of a woman’s life. This exposes the mother and the baby to health risks and complications which include anemia, bleeding, infection and if immediate interventions are not taken this can lead to death or damage of the reproductive organs. It is evident from reports that every day, almost 800 women die in pregnancy or childbirth worldwide. Evidence shows that infants whose mothers die are more likely to die before reaching their second birthday than infants whose mothers survive. And for every woman who dies, 20 or more experience serious complications (UNFPA 2010).
Maternal health services have been improved upon in all the health centers in Asaba LGA, Delta State. However, many women do not utilize these facilities and instead seek delivery care from high risk places. Giving birth without the assistance of a skilled birth attendant can pose life threatening situations incase complications occur during the process. This study, therefore, was set to investigate factors that influence women’s choice of place of delivery in Asaba LGA, Delta State.
1.3 Purpose of the Study
The purpose of this study was to investigate factors influencing women’s choice of place of delivery in Asaba LGA, Delta State.
1.4 Research Objectives
The purpose of the study was achieved through the following objectives:
- To determine how demographic factors influence the choice of place of delivery among women in Asaba LGA, Delta State.
- To establish how socio cultural factors influence the choice of place of delivery among women in Asaba LGA, Delta State.
- To examine the influence of economic factors on the choice of place of delivery among women in Asaba LGA, Delta State.
- To establish how Antenatal Clinic attendance influences the choice of place of delivery among women in Asaba LGA, Delta State.
1.5 Research questions
The study sought to answer the following questions;
- To what extend do demographic factors influence the choice of place of delivery among women in Asaba LGA, Delta State?
- How do socio cultural factors influence the choice of place of delivery among women in Asaba LGA, Delta State?
- To what extend do economic factors influence the choice of place of delivery among women in Asaba LGA, Delta State?
- To what extend does Antenatal Clinic attendance influence the choice of place of delivery among women in Asaba LGA, Delta State
1.6 Significance of the study
The findings of this study may have both theoretical and practical implications for the future of suitability of place of delivery in Asaba LGA. Theoretically, the study may contribute to the advancement of knowledge about factors determining the choice of place of delivery in Delta State specifically Asaba LGA. The study might also have practical significance in that, it may assist in determining the level of utilization of SBAs and TBAs at birth. The findings may be of immediate benefit to the Ministry of Health in the formulation of future public health policies aimed at integrating TBAs in the health system as agents of change to enhance places of delivery. Similarly, results of this study may enlighten the public especially mothers and spouses on the importance of considering a suitable and safe place of delivery. In addition, this can lead to appropriate interventions by non-governmental organizations and other key stakeholders that have established or intend to establish reproductive health programs. The study may also forms a base on which others can develop their studies based on the gaps identified.
1.7 Assumptions of the Study
An assumption is a supposition that a fact is true (Oso &Onen, 2008). This study was guided by the following assumptions; that is, in every homestead visited, there will be a woman of child bearing age. It is also assumed that the respondents will spare their time to fill in the questionnaire and that they will give truthful and honest responses.
1.8 Limitations of the Study
The limitations of the study were; inadequate time to collect data, therefore two research assistants were hired to assist in carrying out the task.
Cases of respondents not cooperating were experienced and even some had to withdraw from the exercise after answering some questions because they were not convinced if the study was done for genuine reasons.
1.9 Delimitations of the study
The study was carried in Asaba LGA, Delta State leaving out other LGAs in the State. The findings of the study may not be generalized to an urban setup since majority of mothers with challenges in choice of place of delivery are mainly in rural set up.
The study also focused on women of childbearing age in Asaba LGA only. The findings therefore may not be generalized to the entire women in the State. Future researchers are encouraged to do further research in this area.
1.10 Definition of terms used in the study
This refers to all females of reproductive age that is, 15 years to 49 years of age.
Choice of place of delivery:
This is the preferred option by the women who are giving birth; it could either be home, health facility or assisted by traditional birth attendant.
No. of children:
This refers to the number of children a woman has at the time of making the choice.
No. of household members:
This refers to the number people in a particular household.
This refers to whether a person is married, single, divorced or widowed.
Level of education:
This refers to the level of schooling a person has reached, that is, primary education, secondary or tertiary education.
This entails the care that is given to women who are expectant or pregnant.
This is the person who makes a choice regarding family issues.
This is the type of work that a person does.
Level of monthly household income:
This refers to the total monthly earnings in a given family.
This refers to what is used to move from one place to another, that is, on foot, motorbike, private or public means.
1.11 Organization of the study
This study is presented in five chapters and is focused towards investigating factors that influence women’s choice of place of delivery.
- Chapter one covers the background of the study, statement of the study, purpose of the study, research objectives, research questions, significance of the problem, basic assumptions of the study, limitations of the study, delimitation of the study, definitions of significant terms used in the study, and the organization of the study.
- The second chapter looks at the literature review of the factors that influence women’s choice of place of delivery, theoretical framework, conceptual framework, gaps in the literature reviewed and summary of literature reviewed.
- Chapter three covers the methodology used for the study. It contains the research design, target population, sample size and sampling procedures, data collection instruments used, data analysis techniques used and ethical considerations.
- Chapter four gives a comprehensive explanation of the tools used for data analysis in this study, presentation and interpretation of the results of the study and the tests that were done to determine associations between independent and dependent variables.
- Chapter five provides a summary of the findings, discussions, conclusions and recommendations of the study and contains suggestions for further studies.
Summary Of The Findings, Discussions, Conclusions And Recommendations
This chapter covers a summary of the study findings, conclusions and recommendations in line with the objectives of the study. The study was aimed at investigating factors influencing women’s choice of place of delivery in Asaba LGA, Delta State. These factors included demographic factors, socio cultural and economic factors.
5.2 Summary of Findings
There was a high response rate of 98% (n=373) women participated. This was a high response rate which provided a guarantee that the findings were a representation of the population. The variables that were used for this study were age, number of children, marital status, decision maker, ANC attendance, education of the mother, income and affordability of health facilities.
Most mothers aged between 25 and 34 years (81.5%) delivered in a hospital or health facility compared to mothers aged 15-24 years (74%) or 35-49 years (54.2%) delivering in hospital or health facilities. Marital status was however, not associated significantly with choice of place of delivery. Hospital deliveries were more common in women with fewer children and smaller family sizes compared to those with more children and larger family sizes. 38.7% of women with more than 5 children and 34.8% of those with family sizes of 7 persons or more delivered in hospitals. Between 64.7 and 90.4% of women with 4 or fewer children delivered in hospitals and 66.3% to 93.5% of women with families of 6 or fewer persons delivered in hospitals.
Regarding level of education there was a consistent increase in the percentages of mothers delivering in hospitals with increasing level of education: 58.4% of mothers with primary education delivered in a hospital (p<0.001), compared to 76.1% of mothers with secondary education (p = 0.019) and 96.6% of mothers with tertiary level education (p = 0.001). The level of spousal occupation was significantly associated with choice of place of birth. Women whose spouses had tertiary education were significantly more likely to deliver in a hospital or facility (86.2%) compared to 72.4% of women with spouses who had secondary education and 52.5% of those whose spouses had primary level education. The primary decision maker within the household had a significant influence on the choice of place of delivery as shown in Table 4.5. Women from households within which the husband was primary decision maker were more likely to deliver in hospital (87.9%), p <0.001 compared to households with female decision makers (59% for household in which the participating woman was the decision maker and 50% in household in which mother-in-law was decision maker).
The women’s occupation influenced choice of place of delivery, while income and common mode of transportation to facility did not influence choice of place of delivery. Civil servant were likely to deliver in hospitals (92.5%) p = 0.004, while farmers were more likely to report that they delivered at home (45%) compared to the women in the remaining occupations. Mode of transportation and income did not influence the choice of place of delivery with most mothers in different income levels and those who used different mode of transportation reporting that they delivered in hospitals, and a significant percentage (11.1% to 35.4%) indicating that they delivered at home.
There was a significant association between ANC attendance and choice of place of delivery and also between difficulties in accessing facility and choice of place of delivery. Failure to attend ANC was strongly associated with home delivery with all three women who did not attend ANC delivering at home, compared to 27% of mothers who attended ANC and delivered at home (p = 0.038).
Seventy-one percent of mothers who had unexpected labour delivered at home and 16 (21.3%) of mothers with unexpected labour delivered at home with the assistance of TBAs. Most women who reported barriers to accessing health care facilities were likely to deliver at home including: 50% of women who thought hospital bills were costly, 66.7% of women reporting that healthcare workers had unfriendly attitudes, and 83.3% of women who indicated that distance to health centre was a barrier to access.
5.3 Discussion of findings
This study documented an increase in hospital deliveries in Asaba LGA, Delta State from 39% to 67.6%. This could be attributed to free maternity services and the beyond zero campaign which is being implemented by the government of Nigeria. Although this is a positive change there is still alot to be done because it is below the set targets at the International Conference on Population and Development(ICPD) whose goal is to have more than 80% of deliveries assisted by skilled attendants globally by 2005, 85% by 2010 and 90% by 2019 (UNFPA). Likewise other study conducted in Maharastra, India stated that percentage of institutional delivery had increased in different time period (Pardeshi et al, 2011). This might be due to the various programs along with safe motherhood and free services for institutional delivery. Safe Delivery Incentive Program (SDIP) and establishment of birthing centres in rural areas play a vital role to increase institutional delivery.
The findings of this study showed that there was a strong association between age of women, number of children they have and the number of household members. This is in agreement with observations in other studies for they showed that healthcare services utilization had a strong statistical association with the age of women, number of children they have and the number of household members. Studies in developing countries have shown that demographic factors such as age, number of children, are associated with the use of the health care services (Sharma et al, 2007; Wong et al., 1987; Obermeyer, 1993). It was well recognized that age plays an important role in women’s utilization of maternal health services. Since older and younger women have different experience; and influence, their behaviour on seeking healthcare also vary, younger women might have enhanced their knowledge of modern medicine and are more likely to utilize modern health facilities than older women. They are likely to have greater exposure and more access to education.
Although marital status has been found to determine place of delivery in other contexts (Say, 2007) and (Stephenson et al.2006) also found marital status, to be important determinants of place of delivery in Nigeria, the findings of this study indicate that marital status is not significantly associated with place of delivery.
Socio cultural factors
In this study, level of education of women, spouse’s level of education and the decision maker in the family were strongly associated with the place of delivery which is also the case in other studies. The result of the study that was conducted in Enugu, Nigeria also found factors like mothers educational level among other social characteristics to be highly associated with place of delivery. Social factors that were found from this study to be associated with hospital delivery were not different from what was found in other studies and they were factors like level of education, spousal level of education and the decision maker in the family. The women with higher education in this study chose health facility delivery more than the less educated women. Studies by (Katung, 2001) and (Ikeako et al 2006) in developing countries have shown that the decision to deliver at home is strongly associated with related to lower educational status. According to these authors, maternal education increases women’s perceived seriousness about maternal health issues.
The results of this study show that occupation is positively associated with choice of delivery. Studies elsewhere have also documented positive relationship between economic status and choice of place of delivery.A number of studies find that formally employed women are more likely to use delivery services (Nwako1994, Onah 2006) while others find that farming women are less likely to have skilled attendance at delivery than women in other occupations (Nwako1994, Addai 2000, Obermeyer,1991). The findings of this study show that there is no positive association between level of monthly income and place of delivery which disagrees with a study by (Mang’ong’o 2013) in Rabai and Kilifi LGAs which indicated that mothers from low income households are more likely to deliver at home.
Antenatal clinic attendance
A study conducted in Russia village Nigeria showed that despite the high number of pregnant women who attended ANC, a lot still preferred home delivery, 74% were attending ANC and yet up to 39% chose home delivery in the index pregnancy. (Envuladu et al 2013). In Nigeria, about 53% of deliveries take place outside health facilities despite more than 93% of pregnant women having at least one ANC visit during pregnancy. The results of this study indicate that ANC attendance is strongly associated with the place of delivery. Mothers who never attended ANC were more likely to deliver at home compared to those who attended ANC and this could be attributed to familiarity with services and encouragement by health workers.
While in some developed countries, it is possible for women to decide to give birth safely at home (Davis, 2000) in developing countries; conditions are not safe enough to encourage women especially those living in rural and remote areas to deliver at home.
This study concludes that hospital delivery is increasing with time in Asaba LGA, Delta State. This is a clear indication that today women are more aware of the need for safe and secure place of delivery where skilled birth attendants are available and incase of emergencies, medical intervention is offered in good time. This could be attributed to free maternity services as this came out clear from the focus group discussions.
From this study, age of mothers, number of children a woman has and the number of household members is strongly associated with the choice of place of delivery. The elderly mothers were more likely to deliver at home compared to the young women.
In this study, level of education and decision maker in the family, were factors that influenced a lot where the mother will deliver their babies. It came out clearly that the higher the level of education the more the hospital delivery was likely to happen. Husbands, older female relatives and the traditional birth attendants all have an influence on place of child delivery.
Poor accessibility to health facilities has been is a major factor that is associated with lack of health facility utilization during the time of delivery for mothers in Asaba LGA.
Occupation plays a major role as to where a woman will deliver her baby. Professionals are most likely to give birth in hospitals.
The study also showed that antenatal attendance influences hospital delivery a lot. Mothers who never attended antenatal clinics are most likely to deliver at home compared to mothers who attended antenatal clinics.
The following recommendations may help women in Asaba LGA and Nigeria at large to make a better choice when the time to give birth reaches.
1. Demographic factors
Advocacy to all women of child bearing age on importance of hospital deliveries, this can be done by the Ministry of Health, Ngo’s and community based organizations. Mothers should be made aware that each pregnancy has its own challenges having delivered before does not put them out of risk.
2. Social factors
Involvement of husbands as key decision makers in the choice of place of delivery during antenatal clinic visits could be one of the best strategies in reduction of home deliveries.
3. Economic factors
The government should focus more on women empowerment through creating entrepreneurship opportunities for them as a measure to make them financially stable and this could of a positive impact on the choices they make during delivery.
4. Antenatal clinic attendance
During antenatal clinic visits health workers should emphasize more on issues like early signs of labour, birth preparedness and expected dates of delivery as a step to reduce home deliveries. They should also encourage mothers to be accompanied by their husbands during these visits.
Health workers should increase the coverage of antenatal care by reaching out to women at the community level through outreach programmes that are geared towards creating awareness that antenatal clinic visits are important for them when they are expectant.
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