DISCUSSION

We examined factors associated with ANC and delivery location among recently delivered women attending an immunization clinic at a tertiary hospital in southeastern Nigeria.

Antenatal Care and Place of Delivery

Notably, the majority of the patients (98.5%) received ANC. The high ANC attendance was similar to that reported in another hospital-based study.[13] The similarity could be attributed to both studies being hospital-based and conducted in an urban center. Because both samples were drawn from health-service users, neither should be interpreted as population coverage. This finding was in contrast to the national estimate from the National Demographic and Health Survey, which reported that only 63% of women received ANC.[14] The difference in findings may be because this study was hospital-based and conducted in an urban area, where attendees are more likely to be more educated and socioeconomically more advantaged than the national demographic survey, which included women in both rural and urban areas. However, up to 9.4% of participants did not attend ANC or attended places where they did not have the opportunity to access the services of a midwife, doctor, gynecologist, or any other person trained to provide ANC services. ANC offers a safety net for pregnant women. It assists in early identification and management of potential complications; monitoring of blood sugar, blood pressure, and other vital signs; educating women on breastfeeding, healthy habits, and newborn care; and provision of supplements such as folic acid and iron. When women do not attend ANC or attend in a place where there is no qualified health personnel, potential pregnancy complications often become undetected and untreated, resulting in severe consequences both to the mother and the newborn baby.

Although the majority of patients (90.6%) delivered in a health care facility, about 9.4% delivered at home, in spiritual houses, or with traditional birth attendants (TBAs), where qualified health personnel are not present. This finding is similar to that done in Nigeria, where it was shown that the majority (75%) of antenatal attendees delivered in a health facility, while 15% delivered with TBAs with insufficient skills to manage complications that may arise during delivery.[15,16] The similarities in findings may be attributed to the fact that both studies were hospital-based and in urban areas. The high level of facility delivery may partly reflect the selected sample: all participants were attending an immunization clinic at a tertiary hospital, and most had also used formal ANC. ANC attendance has been associated with delivery in a health care facility.[16] Women have greater opportunities to reinforce the health messages they receive with more ANC attendances, mainly because this higher number leads to better understanding and compliance.[15] However, in studies comparing rural and urban utilization of skilled versus unskilled birth attendance, as in our study, urban dwellers use skilled birth attendance more than rural dwellers.[17]

Factors Influencing Place of Delivery

This study showed that, to some extent, women and their husbands are responsible for the choice of delivery location. This is consistent with another study in southwest Nigeria, which also noted that spouses primarily determine the place of childbirth.[13] Both studies were hospital-based, and participants were of similar cultural and socioeconomic backgrounds. Where couples choose to have their babies is not necessarily at random. Reasons for choosing a place may include quality of care and safety, cost and financial factors, access and convenience, social and cultural factors, trust and familiarity, as well as medical and obstetrics factors. In this study, the factors rated higher included the competence of obstetricians and midwives (85.9%), the presence of a specialist obstetrician (80.6%), the 24-hour presence of doctors (84.0%), and the availability of health education (78.2%).

In the unadjusted analysis, women’s delivery location in Enugu varied by age, education, occupation, and income, consistent with findings from other similar studies, which showed that certain socio-demographic factors influence women’s choice of place of delivery.[18] Significant relationships between seeking institutional delivery and respondents’ characteristics were found for age (p = 0.010), education (p = 0.001), occupation (p = 0.002), and income (p = 0.001). Patronage of health institutions increased with age: 95.6% of those aged 45 and above preferred health institutions, compared with 80% of those aged 15–24. This finding is in agreement with the findings of other investigators in a similar setting, which also showed that older pregnant women preferred institutional/hospital delivery compared to younger ones in their study.[13] Another study showed that older women aged 40–49 years were positively associated with hospital/institutional delivery, even after adjusting for other confounding variables.[19–21] One possible explanation is that older women or their clinicians perceive greater obstetric risks such as antepartum hemorrhage, preeclampsia/eclampsia, preterm delivery, low birth weight, as well as diabetes in pregnancies. The awareness of this risk may drive older women to the hospital. Those with higher education and income, as well as professionals, had higher proportions seeking care at health institutions than those with lower education and income. This is also consistent with findings from investigators who demonstrated that women with higher education and higher income were significantly more likely to deliver in a health facility.[22,23] These factors are all interrelated. Education improves women’s health literacy and risk perceptions, enables them to navigate the health system, and gives them greater decision-making power and autonomy. Education also correlates with professionalism, employment, and higher family income. In this study, conducted in an urban area, the majority of the women were professionally employed, had consistent incomes, autonomously chose their ANC and delivery sites, independently accessed health institutions for care, and received reliable monthly pay. These employed women, possessing a consistent income, were more inclined to autonomously decide their preferred locations for childbirth and to independently access health facilities for care.

Limitations of the Study

There is a possibility of recall bias, as the women may not have been able to recall events that occurred several months before the survey. Restricting eligibility to women who had delivered within the previous 3 months may have reduced recall error. However, self-reported care location and decision-making remain subject to recall and social desirability biases. This study is limited by its cross-sectional design, which precludes causal inference. It cannot establish that the listed factors caused or influenced the choice of use of maternity services. The sample was drawn from an urban tertiary hospital immunization clinic. It may not represent women who use other facilities, deliver at home, do not attend infant immunization, or experience stillbirth or early neonatal loss. The findings should therefore not be generalized to Enugu State or Nigeria. A larger multicenter study with a higher sample size is needed.