FACTORS INFLUENCING WOMEN'S CHOICE OF PLACE OF DELIVERY IN NIGERIA

1.1 Introduction

Pregnant women who gave birth through Caesarean section are believed to be weak as undergoing a Caesarean section traditionally portrays a sign of failure (Adeoye et al., 2011 and Mboho, Christine & Heather, 2011). Perhaps this could be attributed to the fact that it is surrounded by fear, suspicion, aversion, misconception, guilt, misery and anger (Adeoye et al., 2011). Pregnant women are expected to safely go through the gestation period and have the desired outcome under the presumption that the body is programmed to accommodate the developing fetus while preparing the mother for labor and delivery (Soma-Pillay et al., 2016).

As a prelude to other parts of this study, this chapter will discuss the background upon which this study was initiated, the statement of problems that led to this study, the Aim and Objectives of the study. Others are Significance of the study, Scope of work, Research hypothesis and questions, Limitations of the Study and Definition of technical terms.

1.2 Background of Study

Nigeria contributes about 10% of maternal mortality worldwide and ranks among the top 10 countries with the worst cases of pregnancy-related deaths (Adeoye et al., 2015). Many of the reasons for the pregnancy-related complications and death are preventable, especially when women use obstetric services during pregnancy and deliveries. Indeed, measuring the functionality of a health system can be achieved by calculating how much it positively contributes to reducing maternal morbidity and mortality globally. The use of skilled ANC and birth attendance are proxy indicators (Odetola, 2015). Despite the proven effectiveness of skilled birth attendants (SBAs) in assuring a good outcome for pregnant women and their unborn children (Ezugwu et al., 2014), if the target population does not use the services, the intended results will not be achieved. According to Ezugwu et al. (2014), in situations where pregnant women do not use both antenatal and delivery services, there is a 10-times higher risk for pregnancy complications, including death.

Every pregnancy has associated risks, and none is entirely free from risk (Rothman, 2014). There can be pathological deviations from the routine anatomical and physiological changes of pregnancy, and any effort put in place to monitor specified signs during pregnancy could contribute to improving maternal and fetal outcomes (Shagana et al., 2018). Because of the potential risk during pregnancy, death in childbirth contributes to as many as 211 deaths per 100,000 live births globally, with 94% of all these maternal deaths occurring in lower- and middle-income countries (United Nations Children’s Fund [UNICEF], 2019).

Risk factors associated with increased maternal mortality have individual and country-specific variations, but being an adolescent and having high parity, or the number of times a woman has given birth, is generally associated with having the highest risk for complications and death during pregnancy and childbirth (UNICEF, 2019). Country- specific factors that predispose women to inequalities increase the risk of maternal mortality and tend to be more pronounced in low-income countries (UNICEF, 2019).

Whatever the risk factors, the significant causes of death are severe bleeding, infections, high blood pressure during pregnancy, complications from delivery, unsafe abortions, and existing chronic diseases to a lesser degree (Adeoye et al., 2015; UNICEF, 2019).

As a matter of policy, the Federal Ministry of Health in Nigeria had adopted the WHO recommendation for pregnant women to make at least four ANC visits, with further adaptation to the focused ANC approach that specifies fixed periods during the gestation period for the four visits (Dahiru & Oche, 2015). However, physical access to health facilities may not be the most critical when it comes to utilization. This is evidenced from findings in northern Nigeria that the proximity of health services to pregnant women does not guarantee utilization. Neither does it specifically address the gap between ANC attendance and health facility deliveries (Dahiru & Oche, 2015; Idris et al., 2013). This nonutilization depicts a behavior pattern by pregnant women with underlying socioeconomic and cultural influences that encourage deliveries outside health facilities even after using ANC (Iyaniwura & Yussuf, 2009).

The choice to utilize obstetric services is influenced by interacting social, economic, and health system factors, operating at the household, community, and health provider level and broader social and political levels (Onah et al., 2006). On the demand side, socio-demographic factors, which include place of residence, religion, educational status, tribe, marital status, employment status, husband’s professional and educational levels, age, and parity, were statistically significantly associated with deliveries at health facilities in research by Onah et al. (2006). On the supply side, the choice for utilization was statistically significantly associated with the cost of services, a client’s waiting time, doctors’ and specialist obstetricians’ availability, and their competence (Onah et al., 2006).

1.3 Statement of Problems

Traditionally, Nigerian women are unwilling to have CS because of the general belief that abdominal delivery is reproductive failure on their part regardless of the feasibility of vaginal birth after CS and the decreasing mortality from Caesarean sections. Imperative to the average pregnant woman irrespective of her level of education and parity therefore is CS. Available reports on knowledge of CS amongst women are mainly from tertiary health facilities situated in cities and in the southern parts of the country while little is known about the perception and acceptance of pregnant women towards Caesarean section in Igbinedion University Teaching Hospital in Edo State.

Pregnancy and childbirth are a series of socially encouraged and widely desired physiological activities by women worldwide for a variety of reasons (Soma-Pillay et al., 2016). Nigeria is one of the 10 countries responsible for 60% of all maternal deaths worldwide while contributing 10% of all pregnancy-related deaths, and these deaths are largely preventable (WHO, 2014). With a maternal mortality ratio of 560 per 100,000 women in the country (WHO, 2014), the situation is a public health issue that requires attention. With appropriate behavior changes on the supply side by health providers) and demand side by pregnant women and people associated with them, there may be hope to reverse the trend. Two thirds of maternal deaths are thought to be caused by complications around childbirth that were not predictable during pregnancy, with home delivery being the single most significant contributing factor (Abera et al., 2016). With only 42.9% of births occurring in the health facility (Abera et al., 2016), this continues to be a challenge in Sub-Saharan Africa.

1.4 Aim and Objectives of Study

The aim of the study is to ascertain the Factors Influencing Women's Choice of Place of Delivery in Nigeria. In achieving this aim, the following specific objectives were laid out as follows:

1. To assess the association between socio-demographic factors and the place of delivery used by pregnant women in Lagos State
2. To determine the association between obstetric factors and the place of delivery used by pregnant women in Lagos State for delivery
3. To ascertain the relationship between health service factors, and the place of delivery used by pregnant women in Lagos State

1.5 Research Questions

The study came up with research questions so as to be able to ascertain the above stated objectives. The specific research questions for the study are stated below as follows:

• Is there an association between sociodemographic factors (age, educational status of women and their husbands, wealth status, place of residence) and the place of delivery used by pregnant women in Lagos State?
• Is there an association between obstetric factors (parity, number of children, use of ANC) and the place of delivery used by pregnant women in Lagos State for delivery?
• Is there an association between health service factors (the type of facility, distance from residence, cost of services, quality of care), and the place of delivery used by pregnant women in Lagos State?

1.6 Research Hypothesis

In order to pursue the objective of this study, the following generalized statements have been designed to guide and aids in obtaining the result for the experiment to be conducted. For this work, the null hypothesis will be represented with H0 while the alternative hypothesis will be represented with hypothesis H1.

Hypothesis One

• H0: There is no significant association between sociodemographic factors and the place of delivery used by pregnant women in Lagos State.
• H1: There is a significant association between sociodemographic factors and the place of delivery used by pregnant women in Lagos State.

Hypothesis Two

• H0: There is no significant association between obstetric factors and the place of delivery used by pregnant women in Lagos State.
• H1: There is a significant association between obstetric factors and the place of delivery used by pregnant women in Lagos State.

Hypothesis Three

• H0: There is no significant association between health service factors and the place of delivery used by pregnant women in Lagos State.
• H1: There is a significant association between health service factors and the place of delivery used by pregnant women in Lagos State.

1.7 Significance of Study

The findings from this study would be used in planning strategies towards improving the knowledge, perception and acceptance towards Women's Choice of Place of Delivery in Nigeria.

This study will help in health seeking behaviors among women of child bearing age, which acts as a tool in detecting early, the problems associated with pregnancy and delivery and prompt treatments before it results in complications. It will help in reducing the complications resulting from maternal and child mortality rate in Nigeria especially in Lagos State.

The study will prompt governmental and non-governmental organizations across the country to provide both public and private sectors practicing Caesarean section with adequate information on the factors influencing the perception towards Caesarean section and also pinpoint the areas where more work is to be done with respect to providing quality care and above all, gives room for further studies. The findings from this study can be used to design appropriate and effective enhancement programs aimed at improving knowledge and perception about caesarean section among pregnant women as well as healthcare providers so as to meet up the demands of pregnant mothers seeking care during delivery.

1.8 Scope of Study

The study focuses on the Factors Influencing Women's Choice of Place of Delivery in Nigeria using Lagos State as a case study.

1.9 Limitations of the Study

During the course of this study, many things militated against its completion, some of which are:

1. Time Constraint: The time frame given to accomplish this project was very short due to school academic calendar and it was carried out under pressure which made the researcher not to implement some necessary features.
2. Research material: availability of research material is a major setback to the scope of the study.
3. Frequent power failure: This made the researcher append more money on fuel to ensure sustainable power.
4. Financial Constraint: Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).

1.10 Definition of Terms

Perception: Is the process of recognizing and interpreting sensory stimuli. Learn the definition of perception, how it is related to the five senses, how it differs from reality, and more.

Acceptance: In human psychology is a person's assent to the reality of a situation, recognizing a process or condition (often a negative or uncomfortable situation) without attempting to change it or protest it.

Caesarean Section: Also known as C-section or caesarean delivery is the use of surgery to deliver one or more babies. A caesarean section is often necessary when a vaginal delivery would put the baby or mother at risk.

Knowledge: Familiarity, awareness or understanding of women of child-bearing age in the three selected primary health care centers in Mushin Local Government, about Caesarean section