METHODS

Study Setting/Design

We conducted a facility-based cross-sectional survey from April through October 2025. Participants were recruited from the immunization clinic of Enugu State University of Science and Technology Teaching Hospital, a tertiary public hospital in Enugu, southeastern Nigeria. It is a public hospital that offers free maternal and immunization services and therefore has a high influx of mothers who come to access immunization for their children, irrespective of where they delivered.

Sampling Population

Eligible participants were women who had delivered within the previous 3 months and attended the clinic to immunize their infants. The 3-month interval was strictly applied at each recruitment date to reduce recall errors regarding ANC and delivery experiences.

Sample Size/Sampling Approach

Cochrane’s formula for a single proportion, using a 95% confidence level, an expected proportion of 0.50, and a 5-percentage-point margin of error, gave a minimum sample of 384. After allowing 10% for nonresponse, the target sample was 422. Recruitment continued until 501 completed questionnaires were collected, as more eligible participants and resources became available. We also needed to account for attrition, handle incomplete data that may be removed during data cleaning, and achieve high statistical power. Data collection used a purposive sampling technique.

Ethics

Ethical approval was obtained from the Ethical Review Committee of the Enugu State University of Science and Technology Teaching Hospital, Parklane, with ethical clearance certificate number ESUTHP/C-MAC/RA/034/Vol. 4/34. Participation was voluntary, and written informed consent was obtained. Participants were free to withdraw from the study at any time. Respect for persons, justice, and beneficence were ensured. Confidentiality of information was ensured, and data were securely stored.

Inclusion/Exclusion Criteria

All consenting mothers who brought their children for immunization and delivered within 3 months of the data collection date were included. This restriction was intended to reduce recall bias. Those who delivered more than 3 months before the data collection date, as well as women who came to immunize another person’s child, were excluded.

Data Collection and Management

Data were collected with a pretested structured questionnaire. The questionnaire contained a mix of open- and closed-ended questions, specifically designed to collect information related to the study objectives. These include questions on sociodemographic characteristics, average monthly income, and number of children. Others include questions about perceived factors influencing the location of ANC/delivery, and multiple answers were allowed. Responses to perceived factors that influenced ANC/delivery at the health facility were recorded as “Yes,” “No,” or “Not sure.” Pretesting of the questionnaire was conducted with 10% of the sample at the antenatal clinic. Corrections and modifications of the questionnaires were made before the study. Research assistants were employed and trained on data collection techniques. Before participation, participants were thoroughly informed about the study, and written informed consent was obtained. A total of 800 women were approached; 200 of them were excluded, and 99 declined to participate. Information on socio-demographic characteristics, places of ANC and delivery, and factors determining their choices was collected.

Data Analysis

Completed questionnaires were checked, coded, and entered into IBM SPSS Statistics version 25, and analysis was done. Independent variables included the socio-demographic characteristics such as religion, age, level of education, place of residence, marital status, family monthly income, and number of children. The primary outcome was ANC/delivery in a health facility. A health facility is any place where health care services are offered by trained health care professionals at different cadres to promote, restore, improve, or maintain people’s health. Receiving ANC/delivery in a health care institution in this study includes care in any of the maternity centers, primary health centers, private/mission hospitals, and specialist/teaching hospitals. Missing responses were coded as “99,” indicating no response. Demographic characteristics and descriptive statistics were reported as percentages and frequencies (univariate analysis). Unadjusted associations were assessed using Pearson’s chi-square test or Fisher’s exact test, as appropriate. A two-sided p value below 0.05 was considered statistically significant.