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Barriers to facility-based delivery in Niger State, North Central Nigeria

Authors:
  • NIGER STATE PRIMARY HEALTH CARE AGENCY

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Junaidu Inuwa1
Abdulsalam Ahmed2
Samuel Ndagi Jiya3
Muhammad Khaliliu4
1 The State Program Manager, Saving One
Million Lives Program for Result (SOML
PforR), Niger State Ministry of Health,
Nigeria
2Program Manager, State Emergency Coor-
dinating Centre (SERICC) at the Primary
Healthcare Development Agency Minna,
Niger state of Nigeria
3State Immunization Ocer, Primary
Healthcare Development Agency Minna,
Nigeria
4Senior Technical Adviser, Niger State
Commissioner for Health, Nigeria
Citation: Inuwa, J., Ahmed, A., Jiya, S.N.,
Khaliliu, M.(2018). Barriers to facility-
based delivery in Niger state, North
Central Nigeria. International Journal
of Perceptions in Public Health, 2(2):
108-114.
w w w . i j p p p h .o r g
* Corresponding author:
Dr. Abdulsalam Ahmed
Deputy Program Manager, Primary
Healthcare Development Agency
Minna, Nigeria
E-mail: yatalaa@gmail.com
108
International Journal of Perception in Public Health
Barriers to facility-based delivery in Niger State, North Central Nigeria
Abstract
Background: Institutional based delivery
correlates directly in reducing death arising from
complications of pregnancy. Despite various
government interventions and policies to improve
skilled birth attendant, facility- based delivery is
still very low in Niger state. Objectives: The
purpose of the study was to determine the cause
of low utilisation of facility for delivery in Niger
state. Methods: The research was a quantitative,
cross sectional study carried out across the 25
LGAs of Niger state in the north central Nigeria. A
pretested self-administered questionnaire in
English language was administered on a
cross-section of 408 women of reproductive age
that delivered in the last 2 years. SPSS version 20
was used to analysed the study. Chi-square was
used to test association between the covariates
and dependent variables. Results: About 86% of
the participant have attended antenatal clinic at
least ones, with median visits of 4. Only 42.8% of
the respondents delivered in the health facilities.
The factors that had signicant dierence with
facility based delivery include having higher
education (p= 0.000), been employed (p= 0.005).
Those that attended antenatal clinics (p=0.000)
are more likely to deliver in the hospital than
those who do not attend. Those of Nupe aliation
(p=0.008) were more likely to deliver in the health
facility than other ethnic groups. Conclusion:
Despite the high ANC utilisation found in this
study, the proportion of women who used health
facility for delivery is low, and the major factor
responsible was sudden onset of labour, which is
usually due to lack of planning stemming from
low quality antenatal care.
Keywords: Nigeria, Delivery, Antenatal care,
pregnancy, Health facility
Volume 2 Issue 2, March 2018
Original Article
DOI:10.29251/ijpph.201834
Inuwa et al. 2018
109
Volume 2 Issue 2, March 2018
Introduction
The global maternal mortality burden is
highest in south-east Asia and sub-Saharan
Africa and jointly they contribute about
85% of the burden (WHO, 2012). In
Nigeria, maternal mortality ratio is still
high currently at 545/100,000 live births
(NDHS, 2013). This High ratio straggled in
Nigeria with substantial variation across its
region (Olatunji and Sule-Odu 2001, Tukur,
Jido et al. 2008). According to DHIS (2016)
the maternal mortality in Niger State is 452
per 100,000 live births and the major
causes are obstetric hemorrhage,
eclampsia, obstructed labor, and infection
which are largely preventable. Lack of
skilled birth attendant could be considered
as one major factor in maternal and infant
morbidity and mortality (WHO, 2005).
In line with this, Gabrysh and Campbell
(2009) recommended access to skilled
birth attendant so that complications of
pregnancy and childbirth are recognized
early and referral to the next level of care.
Similarly, Kebede, Gebeyechu and
colleagues (2013) stated that one of the
manifested intervention to reduce
maternal morbidity and mortality is facility
-based delivery. This is because the
proportion of having facility birth is closely
related to delivery with skilled assistance.
In Nigeria, skilled birth delivery has not
improved much (NDHS 2013). Despite,
clear evidence of the benet of facility-
based delivery, home deliveries is still the
cheapest options in low resource settings.
Since the birth of safe motherhood
initiative program in Nigeria in 1987,
several other initiatives have been done in
our country to improve access to maternal
care; these initiatives have contributed to
much more access to antenatal care than
access to hospital delivery. Maternal
morbidity and mortality remains a public
health challenge, and this is closely linked
to non-institutional delivery. Previous
studies alluded evidences on factors
contributing to non-institutional delivery
service utilization which was consistently
been linked with low education,
socioeconomic status as well as physical
barriers like long distance or bad terrain to
health facilities. See for example, (Brieger,
Luchok et al. 1994; Bolam, Manandhar et
al. 1998; Amooti-Kaguna and Nuwaha
2000; d'Ambruoso, Abbey et al. 2005;
Borghi, Ensor et al. 2006; Bohren, Hunter
et al. 2014). Several studies have been done
globally regarding factors that aect facility
-base delivery, and no studies have been
done in Niger State to determine the low
utilization of facility for delivery. This
study is therefore meant to nd out factors
that prevent delivery in health facilities
among pregnant women in Niger State and
knowing these factors will help to improve
delivery in health facilities and will be
useful for the community, district and
regional level in planning, implementing
and evaluating various interventions
related to research ndings to reduce
maternal mortality rate across the state.
Data and Methods
Study design and setting
The research is a descriptive cross-
sectional study carried out across the 25
LGAs of Niger State North Central of
Nigeria. Quantitative approach was
adopted for the study. A pretested self-
administered questionnaire in English
language was use to collect information on
women of reproductive age that delivered
in the last 2 years. Medical personals were
trained as survey assistants to assist
respondents that cannot read or write to
complete the questionnaires.
Sampling Strategy, Data Management
and Analysis
Niger State is comprised of 3 geopolitical
zones, which in turn comprised of 25 Local
Government Areas (LGAs) and 143 districts.
Niger State has a comprehensive list of all
health facilities in the state, as well as a list
of all of the settlements served by each
health facility, and the populations of each
settlements. The state has an approximate
population of 5.7 million people. The target
Inuwa et al. 2018
110 Volume 2 Issue 2, March 2018
population for this study was women of
child bearing age that are residing in Niger
State. From projections of 2006 census it is
about 1,214,094 making up about 22% of
the population of the state. The sample
size was calculated using Yamanes formula
of
no = N__
1+N (e2)
Where n0 = sample size
N= target population
E= level of precision
Substituting into the equation
= 1,214,094/1+ 1,214,094 (0.05)
= 399
App = 400
This was increase to 420 to allow chance of
fallout. Proportionate stratied random
sampling was used to select the
participants. The state is divided into 25
LGAs and 274 political wards. The political
wards represent a stratum. From each
stratum, a settlement and a household are
randomly selected and nally the
participants are selected using the
systematic nth number of every third
woman. The inclusion criteria were women
that delivered within last 2 years. The data
was analysed using statistical package of
social science (SPSS) version 20.
Results
The socio-demographic characteristic of
the respondent for these studies includes
n % p- value
Age Group
16-20
21-25
26-30
31-35
36-40
41-45
46-50
32
105
140
82
38
4
1
8.0
26.1
34.8
20.4
9.5
1.0
0.2
Educational Status
No Formal Education
Primary Education
Secondary Education
Tertiary Education
Others
254
48
73
29
3
62.4
11.8
17.9
7.1
0.7
0.000
Occupational status
Unemployed
Self employed
Employed by government
others
224
163
20
1
54.9
40.0
4.9
0.2
0.005
Ethnic Aliation
Gwari
Hausa
Nupe
others
73
92
133
109
17.9
22.5
32.6
26.7
0.008
Religious Aliation
Islam
Christianity
others
336
70
2
82.4
17.2
0.5
0.997
Marital status
Single
Married
Divorce
Widow
8
390
8
2
2.0
95.6
2.0
0.5
0.631
Antenatal care status
yes
No
353
55
86%
14%
0.000
Table 1. Socio-demographic characteristics of respondents N= 408
Inuwa et al. 2018
111
Volume 2, Issue 2, March 2018
age, ethnic and religious aliation,
educational level, occupational and marital
status. A total of 408 women with children
less than 2 years were enrolled for the
study, they were within the age of 17 and 47
years. The median age of the respondents
was 28 years (Std 5.479) and the majority of
them were mothers (81.3%) between 21 and
35 years, 6 of the respondent dont know
their age, see table 1. More than half
(62.4%) of the respondent dont have any
formal education, whereas 12%, 18% and
7% have primary, secondary and tertiary
education respectively. About 55% of the
respondents were unemployed, about 45%
were either self-employed or employed by
the governments. More than three quarter
of the respondents are Muslim (82%) and
married (96%). And about three-quarter of
the respondents belong to the major ethnic
aliations of the state (Nupe 33%, Hausa
23%, Gwari 18%) and nearly one quarter of
the respondents are from other ethnic
background.
The proportion of antenatal service
utilization
Table 1 also showed that out of the 408
women sampled 86% have attended
antenatal at least ones, with median visits
of 4. For those that did not visit ANC, 42 %
of them didnt see the importance of doing
so, 24% did not attend because of long
distance of health facility from their
homes. 22%, 6% and 4% did not attend
ANC because of high cost of service, bad
behavior of health worker and husband
refusal respectively see gure 1.
The proportion of health facility base
delivery service utilization
Only 42.8% of the respondents delivered in
the health facilities. More than half of the
respondents delivered either at their
homes, at the traditional birth attendant
(TBA) home or even at the health workers
home, see gure 2. Table 2 also showed
that about one-quarter of the respondents
admitted to have delivered where they did
not intended. And the majority of them
(77%) intended to deliver in the health
facility. Finding from gure 3 showed that
45.1% of those that deliver outside the
health facility (representing 18.1% of the
total respondents), do so because of
sudden onset of labor. Other reason for
lack of facility deliveries are shown in
gure 3. If a woman is referred to a district
hospital, 44.8% used public transport, 44.6
used own transport, only about 0.7% of the
respondents benets from ambulance
referral and 4.7% of the respondents used
other means of referral such as walking.
Figure 1. Reasons for not attending antenatal
Inuwa et al. 2018
112 Volume 2 Issue 2, March 2018
Predictors of health institutional base
delivery utilisation
The sociodemographic correlates of
women utilisation of place of delivery is
presented in table 1. Chi-square was used
to test association between the covariates
and dependent variables. The factors that
tends to have a signicant dierence with
facility based delivery include having
education (p= 0.000) when compared to no
formal education or less education, been
employed (p= 0.005) either by the
government or self-employed when
compare to unemployed status. Those that
attended antenatal clinics (p=0.000) are
more likely to deliver in the hospital than
those who do not attend. Those of Nupe
aliation (p=0.008) are more likely to
deliver in the health facility than Hausa
and Gwari. No association was found
between religion (p=0.997), ethnic
aliation, marital status (p=0.631) and
place of delivery.
Discussion
This study showed high coverage of ANC
(86%) and moderate facility-based delivery
utilization (42.8%). The clear dierence in
the ANC and hospital delivery utilization is
similar to the ndings in Envuladu et al.
(2013) where ANC is about 74% coverage
and 39% women prefer home delivery. The
percentage of home deliver are also similar
with the ndings in Ilesha, Nigeria (44.2),
Rural Zambia (57%) and even higher values
in Kenya. This further substantiate that
women in developing countries still prefer
non -institutional delivery. However, the
value of facility delivery in this study is
higher than the value of NDHS, (2013), this
dierence could be that not only that free
delivery initiatives was started by the Niger
State Government about a year prior to this
research and but also because a lot of
contributions had been made to change
the awareness of women and communities
on utilization of institutional delivery.
This study also found out that, utilization
of facility based delivery depended on the
circumstance around labour. Sudden onset
of labour was found to be strongly linked
with home delivery, the nding is similar
with ndings in (Mrisho, Schellenberg et
al. 2007; Moore, Alex-Hart et al. 2011). The
ability to detect labour early may be a
major factor in determining where the
women deliver and this is an essential skill
received routinely during antenatal visits.
Frequency Percent
Was that the place you
intended to deliver
Yes
No
304
99
74.6
24.3
If no, where did you in-
tended to deliver
Own home
TBAs
Health facility
12
11
77
12
11
77
Means of transport
Own transport
Public transport
Ambulance
Others
182
199
3
19
44.6
44.8
0.7
4.7
Figure 2. Place of delivery Table 2. Delivery characteristics
Inuwa et al. 2018
113 Volume 2 Issue 2, March 2018
According to Egharevba, Pharr et al. (2017)
when labour allowed time for women to
get to a healthcare facility, they are more
likely to deliver at a healthcare facility.
Other causes of preference of home
delivery are lack of transport to health
facility (12.2%), poor believe to modern
medicine (13.4%), high cost of services
(11%), long distant to health facility
(10.4%), bad behavior of health workers
(6.7%) and others (1.2%). This is similar to
nding at dierent time, see for example
(Brieger, Luchok et al. 1994, Bolam,
Manandhar et al. 1998, Amooti-Kaguna and
Nuwaha 2000, d'Ambruoso, Abbey et al.
2005, Borghi, Ensor et al. 2006, Bohren,
Hunter et al. 2014). Increased maternal
education was signicantly associated with
facility based delivery this is consistent
with previous ndings, see for example
(Duong, Binns et al. 2004, Onah, Ikeako et
al. 2006, Dhakal, Van Teijlingen et al. 2011,
Egharevba, Pharr et al. 2017). This is
possible not only because education can
help people to understand and appreciate
the importance of healthcare facility
delivery but also because education can
inuence hospital delivery through its
eects on socioeconomic status that can
inuence the ability to aord transport to a
healthcare facility during labor.
Conclusion
Despite the high ANC utilization found in
this study, the proportion of women who
used health facility for delivery is low, and
the major factor responsible was sudden
onset of labor, which is usually due to lack
of planning stemming from low quality
antenatal care. Other hindering factors are
lack of transport to health facility, long
distant to health facility, bad behavior of
health workers, poor believe to modern
medicine, high cost of services. On the
other end factors promoting facility based
delivery were education, occupation,
ethnic aliation, use of ANC. To improve
facility based delivery, ANC should be well
package with robust information for the
attendees and education should be
provided on how to detect labor signs
early and to seek early care in labor,
encourage them to prepare for childbirth
nancially and psychologically. For women
to be embroil in decision making process
concerning their health, empowerment in
the form of education and self-sucient
should be promoted.
Conicting interest
The authors declared that they have no
competing interest.
Figure 3. Reasons for not delivering in the health facilities
Chowdhury et al. 2017
114
Volume 1, Issue 5, December 2017
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This nested case-control study compares the characteristics of mothers having home or institutional deliveries in Kathmandu, Nepal, and explores the reasons given by mothers for a home delivery. The delivery patterns of mothers were identified in a cross-sectional survey of two communities: an urban area of central Kathmandu (Kalimati) and a peri-urban area (Kirtipur and Panga) five kilometres from the city centre. 357 pregnant women were identified from a survey of 6130 households: 183 from 3663 households in Kirtipur and Panga, 174 from 2467 households in Kalimati. Methods involved a structured baseline household questionnaire and detailed follow-up of identified pregnant women with structured and semi-structured interviews in hospital and the community. The main outcome measures were social and economic household details of pregnant women; pregnancy and obstetric details; place of delivery; delivery attendant; and reasons given for home delivery. The delivery place of 334/357 (94%) of the pregnant women identified at the survey was determined. 272 (81%) had an institutional delivery and 62 (19%) delivered at home. In univariate analysis comparing home and institutional deliverers, maternal education, parity, and poverty indicators (income, size of house, ownership of house) were associated with place of delivery. After multivariate analysis, low maternal educational level (no education, OR 5.04 [95% CI 1.61-15.8], class 1-10, OR 3.36 [1.04-10.8] compared to those with higher education) and multiparity (OR 3.1 [1.63-5.74] compared to primiparity) were significant risk factors for a home delivery. Of home deliverers, only 24% used a traditional birth attendant, and over half were unplanned due to precipitate labour or lack of transport. We conclude that poor education and multiparity rather than poverty per se increase the risk of a home delivery in Kathmandu. Training TBAs in this setting would probably not be cost-effective. Community-based midwife-run delivery units could reduce the incidence of unplanned home deliveries.
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In order to understand factors influencing choice of delivery sites in Rakai district of south-western Uganda, eight focus group discussions based on the Attitudes-Social influence-Self efficacy model were held with 32 women and 32 men. Semi-structured interviews were also held with 211 women from 21 random cluster samples who had a delivery in the previous 12 months (from 2 June 1997). Forty four percent of the sample delivered at home, 17% at traditional birth attendant's (TBA) place, 32% at public health units, and 7% at private clinics. Among the factors influencing choice of delivery site were: access to maternity services; social influence from the spouse, other relatives, TBAs and health workers; self-efficacy; habit (previous experience) and the concept of normal versus abnormal pregnancy. Attitudinal beliefs towards various delivery sites were well understood and articulated. Attendance of ante-natal care may discourage delivery in health units if the mothers are told that the pregnancy is normal. In order to make delivery safer, there is need to improve access to maternity services, train TBAs and equip them with delivery kits, change mother's self-efficacy beliefs, and involve spouses in education about safe delivery.