1.1 Background to the Study
Child delivery is a critical and sensitive stage of pregnancy. The day of delivery is a day when the pregnant woman needs the help of someone to bring forth her child safely. As much as a personnel is needed to help her in delivering safely, place of delivery is also important; Child birth and its process are one of the most significant life events to a woman (Yibeltal T., Yohana J.M & Thupayagale – Tshweneage G. 2015).During pregnancy women have intention of delivering their babies in different places of birth, which is personal to them. These pregnant women may register in public health facilities with skilled birth attendants, but some also register with places like Traditional Birth Attendants (TBAs), Faith-Based Organization like Mission Birth Attendants (MBA) belonging to religious groups such as churches and Muslims for different purposes, personal to them. Some women do not register with Public Health Facilities at all, so they do not attend Ante-Natal Clinics (ANC) until the day of delivery.
The Encarta dictionary defines intention as something that somebody plans to do, or the quality or state of having a purpose in mind. During pregnancy, women may decide to deliver their babies in different places which can be in urban or rural area, and these pregnant women could be literates or illiterates without considering the consequences of their decision on themselves and the unborn babies.
According to WHO (2017), United Nations through Millennium Development goals have galvanized efforts to improve child survival (MDG 4) and maternal health (MDG 5). The goal of MDG 4 is to reduce child mortality by two thirds which is under 5 mortality rate, while that of MDG 5 is to improve maternal health by 2015 in which the target is to reduce by three-quarter both between 1990 and 2015 (BMC Med. 2013). The global maternal mortality rate declined by 44% during the MDG era equating to annual average of 2.3% between 1990 and 2015. To achieve the Sustainable Development Goal (SDG) by 2030, accelerated progress is now needed in achieving the SDG 3.1 will require a global annual reduction of at least 7.3 per cent (World Health Statistic 2016). United Nations Secretary General opined that to achieve the ambitious target is reducing maternal death to fewer than 70 per 100,000 live births globally (UNDP 2015).
According to UNICEF, (n. d.) having babies in developing nations may be life threatening. Literally in every minute, a woman dies from avoidable complications caused by pregnancy, this adds up to approximately half a million fatalities per year. In Nigeria alone, maternal mortality rate reaches up to 3,200 women (number of women per thousand births, 42 days after child birth). WHO (2015) opined that every day in 2015, 16,000 children under 5 continue to die mostly from preventable causes. Child survival must remain a focus of the new sustainable development agenda (WHO 2017).
The major problem of high infant and maternal mortality rate in Nigeria is lack of access to health care; and prevalence of child marriage. Women in urban areas have more opportunity to receive health care in public and private health facilities. Most of the women in the rural area cannot afford the transport to the health facilities due to far distance from their communities especially at night so, they have to settle for individuals, quack doctors and nurses, TBAs, MBAs or no help at all during delivery. Many of the TBAs do not have skills and training necessary for delivering a baby. For example, they are not able to treat complications that occur during child birth nor can they perform Cesarean section. Nigeria has a high poverty rate, according to UNICEF (2010), Nigeria has a high poverty rate with 64.4% of the population lived in extreme poverty and 83.9% of the population lived in moderate to extreme poverty. The fact that many people cannot afford the health care needed by them contributes to Nigerians high maternal mortality rate. Poverty can be a reason why pregnant women may decide not to deliver at the health facilities where they do their ANC.
The major cause of neonatal death in 2010 were preterm birth complication, intrapartum complications and pneumonia/sepsis while the major causes of maternal death in 2010 were haemorrhage, hypertensive disorder, abortion, sepsis and other direct or indirect causes (BMC 2013).However, to prevent intra partum complication such as obstructed labour and haemorrhage, the two leading causes of maternal death, managing babies that are born very early and treating neonatal sepsis, all require good practices at the time of labour and delivery, preferably access.
1.2 Statement of the Problem
The World Health Organization (WHO) estimates that worldwide, 358,000 women die annually from pregnancy and child birth related complications; with sub-Saharan Africa and South Asia accounting for 87% of these deaths (Joyce et al, 2012, The World Bank, UNFPA, UNICEF n d WHO 2010). Maternal mortality rate in Nigeria is high. RSS (2015) opined that Nigeria is second to India in terms of the number of maternal deaths and its experiences, along with four other countries (Pakistan, the democratic republic of Congo, China and Ethiopia). So Nigeria is one of the groups that makes up more than 50% of the maternal mortalities that occur in the world and the maternal mortality rate was 560 per 100,000 live births in 2013. According to UNICEF, (2010) Nigeria loses 145 women to maternal mortality each day which is also linked to Nigeria’s high rate of deaths for children under five.
NDHS report (2008) states that 58% of women received ante-natal care from a trained health professional at least once during their pregnancy (87% in the South West and South East, 31% in the North West). Only one percent of mothers with no education received ANC services from a health professional, compared with 97% of mothers with more than a secondary education. Thirty-nine percent were delivered by trained health professionals and only thirty six percent had their babies in a health facility. From the researcher’s experience in her place of work, many of the pregnant women who registered in the health facilities and attended Ante-natal clinics are not usually seen at the time of delivery.
Public health facilities seldom have unbooked patients who are in labour and did not experience any ante-natal care during pregnancy at all. Though, WHO recommends one midwife per every 175 pregnant women but this standard could not be achieved because many countries like Nigeria have shortage of medical professionals (Naume et.al 2014). Since the outcome of each person’s labour and delivery cannot be predicted, there has been a serious concern because some women develop life threatening complications during pregnancy, labour and puperium which needs the attention of skilled health worker (midwife) – this results to death of some women or newborn babies. The aim of this study is to examine the determinants of birth delivery intention among pregnant women in Abeokuta South Local Government area of Ogun State, Nigeria.
1.3 Objective of the Study
The general objective of this study is to examine the determinants of birth-delivery intentions among women in Abeokuta South Local Government Area of Ogun State, Nigeria. The specific objectives are to:
- describe the socio-demographic characteristic of the women in the study area;
- examine the factors that lead to either home or institutional delivery among women in the study areas;
- determine the knowledge of women about the birth-delivery intention at health institutions in the study area;
- examine the determinants of home and institutional delivery by women in the study area;
- determine the perception of women towards attending ante natal clinics in the study area and
- Identify the challenges facing women about birth-delivery intention in the study area.
1.4 Research Questions
The following research questions were determined;
- What are the socio-demographic characteristic of the women in the study area?
- What are factors that led to either home or institutional delivery among pregnant women in the study area.
- How knowledgeable are the women about the birth-delivery at health institutions in the study area??
- What are the determinants of home and institution delivery by women in the study area
- What are the perceptions of women towards home or institutional delivery by the women in the study area?
- What are the challenges facing women about birth-delivery in the study area?
The hypotheses of the study are all stated in null form
H01. There is no significant relationship between the socio-demographic characteristics of the women and the determinants of home and institutional delivery by women in the study area.
H02There is no significant association between the socio-demographic characteristic of the women and the perceptions of women towards home or institutional delivery by the women in the study area.
1.6 Justification for the Study
The main justification in this study is that when women of childbearing age get pregnant, their intention to deliver is often directed towards delivering in the health facility that is established or delivering outside the health facility in the care of TBAs or Faith Based Organization who are also called Mission Birth Attendants. Most often, these women that deliver outside the health facility experience complications and are rushed to hospital for completing the delivery. This experience is said to contribute to maternal mortality prevalence in Nigeria. A number of studies had been done why this changing decision to deliver in the place that is known to be safer, but outcome of these studies are not satisfactory to explain the dynamics of what is going on. However, a study that will explore determinants of birth-delivery intention may be well positioned to provide explanation for the various
reasons offered to elect to deliver outside the health facility. This study is significant because measuring level of birth – delivery intention serves as a predictor of actual delivery and therefore factors that will influence this birth – delivery intention will adequately inform on the likelihood of delivery in a recognized health facility.
The instrument developed in this study will serve as a rapid assessment tool to determine the likelihood of pregnant women delivering in the health facility or outside the health facility so that individual can be followed up carefully to ensure that they deliver safely in the accredited delivery health facility. Skilled antenatal care and birth attendance has been advocated globally as the most crucial intervention to reduce maternal mortality. Maternal deaths could be prevented if women were able to access and utilize good quality health services, especially when complications arise (Thaddeus and Maine, 2009). However, in reality, most women experience serious barriers to accessing services or even if they do reach them, the services themselves are often of insufficient quality or effectiveness.
Access to information about maternal services should be available in the community to help women make choices about who to see and where to go, as well as decide the type of care they require. Information about family planning services can help reduce unwanted pregnancies and their adverse consequences. Access to health care particularly at the critical time of birth, can help ensure that childbirth is a joyful event (WHO, 2010). Access means that women can reach maternal health care easily and not be deterred by cost or poor treatment by staff. Women have been seen to travel long distances to access quality health care despite a ready availability of primary health care facilities around where they live, work and school. However, lack of transport makes it difficult for pregnant women or women in labour to reach help quickly. Fees charged for health care often put women off having their babies in hospitals or even seeking help when complications arise. Many women also say they prefer to rely on traditional birth attendants because health workers are rude and unsympathetic.
The role of TBAs remains significantly important at the community level as well as to pregnant mothers. Several qualitative studies in developing countries suggest that for many women, TBAs are the preferred community-based provider to consult with and to help them during delivery. This phenomenon might stem from either the role of TBAs in helping pregnant mothers during delivery; supporting services for household chores in the week after delivery; or the elderly perception that the majority of birth outcomes are positive after getting help from TBAs. Additionally, the spiritual role of TBAs and FBOs in appealing for the blessing of the spiritual ancestors of the community and family is also thought to be important.
1.7 Operational Definition of Terms
Antenatal Care: refers to the proportion of pregnant women who had attended ante natal clinic at least one or four times and the service was provided by skilled health worker (doctors, nurse, midwives). Antenatal Care (ANC) means “care before birth”, and includes education, counseling, screening and treatment to monitor and to promote the well-being of the mother and feotus.
Intention: refers to the extent to which a woman is capable to make independent decisions and take appropriate action on matters bordering them on their reproductive health choices and behaviors.
Women: refers to married or in union who are on modern contraception methods
Home Deliveries: refers to the proportion of women that gave birth in homes or places that are not health care facility within the study areas.
Institutional Deliveries: refer to the percentage of women that gave birth in modern health facilities whether public or private owns.
Maternal Death: refer to as the death of any woman while pregnant or within 42 days of termination of pregnancy that may be from any cause related to or aggravated by pregnancy or its management schedule, irrespective of the duration and size of the pregnancy, but not from accidental or incidental causes.
Maternal Mortality Rate: refers to as the annual number of female deaths per 1,000 live births women in the reproductive age-group (15 − 49 years) in a particular year.
Traditional Birth Attendants: refers to non-formally trained community based individuals that provide prenatal, natal and post-natal care to women and other health related issues.