INTRODUCTION

Maternal mortality remains concentrated in low- and middle-income countries, where in 2023, approximately 92% of the 260,000 maternal deaths occurred, with sub-Saharan Africa carrying the largest share of global maternal deaths.[1] Recent international estimates place Nigeria among the countries with the greatest number of maternal deaths, accounting for 28.3% of all the world’s maternal deaths, and reporting a “maternal mortality ratio of 993 per 100,000 live births.”[2] About one out of every 22 parturients in Nigeria is at risk of death due to pregnancy, delivery, or during the postnatal period.[3] Poor medical infrastructure, pregnancy complications, weak referral systems, a dearth of healthcare workers, and poor health-seeking behavior are associated with increased maternal mortality rates in many countries, including Nigeria.[4] There is a further shortage of health care workers in low- and middle-income nations due to the brain drain of health workers (especially in Nigeria) seeking greener pastures and access to standard, up-to-date equipment to improve their competencies.[5] Evidence has shown that the utilization of the skilled birth attendant (SBA) and the patronization of the health facilities during childbearing can improve delivery outcomes and decrease maternal death and obstetric complications.[6,7] In a study done in northern Nigeria, only about 33.1% of deliveries took place in hospital facilities and were supervised by an SBA (including nurses, midwives, and doctors).[7] Serious obstetric complications may arise without warning, underscoring the importance of timely access to skilled personnel and emergency obstetric care.

The percentage of births overseen by trained health professionals, often cited as an effective indicator of progress in maternal and newborn health globally, has remained stagnant over the last 10 years.[8] In Nigeria, many women continue to deliver their babies at home and in locations that are not healthcare facilities, often without the presence of qualified health personnel, even with the availability of free newborn and maternal health services at public healthcare facilities in certain states.[9–11] Some women attend antenatal care (ANC) in formal health facilities but give birth elsewhere, leaving a gap between antenatal contact and access to skilled care during delivery.[12]

Clinicians at the study hospital have observed that some women seek care from both formal facilities and unskilled providers during the same pregnancy. This observation prompted the present study. Some of them who had ANC with SBA in the public health centers end up delivering their babies with unskilled birth attendants. They are only referred due to complications to the same facility with skilled personnel where they initially registered. Oftentimes, they present late with severe complications that would have been prevented. This study therefore examined factors associated with ANC and delivery location among postpartum women attending the immunization clinic at Enugu State University of Science and Technology (ESUT) Teaching Hospital.