TABLE OF CONTENTS.

Title page                                                                                                  i

Approval                                                                                                        ii

Certification                                                                                                             iii

Dedication                                                                                                            iv

Acknowledgements                                                                                         v

Table of  Contents.                                                                                              vii

List of Tables                                                                                                  ix

List of Figures                                                                                                 x

Abstract                                                                                                    xi

CHAPTER ONE: INTRODUCTION                                                 1

 Background to the Study                                                                          1

Statement of Problem                                                                                                3

Purpose of the Study                                                                                          4

Research questions                                                                                           5

Significance of the Study                                                                         5

Scope of the study                                                                                         5

Operational definition                                                                                          6

CHAPTER TWO: LITERATURE REVIEW                                                7

Conceptual review                                                                                         7

Concept of birth place                                                                                         7

The concept of health care provider                                                                7

The traditional medical practitioner or traditional healer              8

Healthcare providers during delivery                                                            9

Skilled birth attendant                                                                                           9

Consequences of delivering in non-health facility                                     15

Determinants of choice of healthcare provider during delivery among women           16

Socio-Cultural Factor                                                                      16

Socio-cultural factors considered here are:                                         16

Wanted or Unwanted pregnancy                                                                 21

Review of Related Theories                                                                      25

Anderson’s Model Of Health Services Utilization                               25

Relating the theoretical framework to this work:                                      27

Primary determinants:                                                                                    27

Health system                                                                                            28

External environment                                                                                       29

Health Behaviour                                                                                           29

Health Outcome                                                                                                  29

Empirical   Review                                                                                  30 

Summary of Literature Review                                                                      39  

CHAPTER THREE: METHODOLOGY                                                  40

Introduction                                                                                                     40

Research Design                                                                                           40

Area of study                                                                                                40

Target population                                                                                         42       

Sample                                                                                                          41

Instrument for data collection                                                              41   

Validity of Instrument                                                                                         41

 Reliability of Instrument:                                                                            42  

Ethical Consideration                                                                              42

Procedure for data collection                                                                    42

Method of data analysis:                                                                         42

CHAPTER FOUR: PRESENTATION OF RESULTS                                  43

Test of Hypotheses                                                                                      53

Summary of Finding                                                                              57

CHAPTER FIVE: DISCUSSION OF FINDINGS                                         58

Objective one                                                                                        58

Objective two                                                                                              59

Objective Three                                                                                                 61

Objective four                                                                                                    62

Conclusion                                                                                                       67

Nursing  implication                                                                               67

Recommendations                                                                                                68

Limitations of the study                                                                       69

Suggestions for further studies.                                                                 69

Summary                                                                                                      69

References                                                                                                   71

Appendix i                                                                                      75

LIST OF TABLES

Table 1            showing the socio-demographic profile of the respondents             44 

Table 2:           Where the respondents had their last baby.               46

Table 3:           Responses on reasons for women’s choice of birth places.                            47

Table 4:           Responses on who took the delivery of the last baby                                                48

Table 5:           Factors that influence women’s use of birth attendants during delivery.      49

Table 6:           Reasons for wanting to use the same birth place for delivery in future.        51            

Table 7:           Reasons for not wanting to use the same birth place for delivery in future.                                                                  52

Table 8:            Relationship between primiparous and multiparous women in the use of birth attendants  during delivery.                            53

Table 9:           Age cross tabulated with place of delivery                                                    54

Table 10:         Place of delivery cross tabulated with marital status                                     55

Table 11:         Level of education cross tabulated with place of delivery                            55

Table 12:         Parity of respondents crosstabulated with place of delivery                          56

LIST OF FIGURES

Figure 1 on whether the respondents will want to use the same birth place in future            50

                                                          ABSTRACT

Birth place and birth attendants during delivery are crucial factors in reducing maternal and newborn morbidity and mortality. This study investigated the choice of birthplace and use of birth attendants during delivery and also the factors influencing these choices among child bearing women in Akanu, Ohafia community of Abia State. The need for this study arose because women attend antenatal clinic during pregnancy but do not come to the health facility to deliver their babies; they are only seen when complications arose.  Four objectives were set:  To determine women’s choice of birth places in Akanu Ohafia, elicit reasons for their choice of birth places, identify women’s use of birth attendants during delivery and the factors influencing the use of birth attendants. Cross sectional descriptive survey design was adopted for the study.  Total population of 313 women who gave birth between January and December 2012 were used for the study. Data were collected using researcher developed structured questionnaire. Data analysis was done using frequency counts and simple percentages and data presented in tables and pie chart. Mean and standard deviation were used for analysis of the demographic characteristics while Fishers exact test was employed in testing the two null hypotheses at 0.05 level of significance. The findings on choice of birthplace  revealed that,  hospital/health centre ranked highest with 67.6%, TBAS place 13.7%,  church and spiritual homes  10.2 % and  home  8.6%%.   On the reasons for choice of birth place, respondents chose their places of delivery based on different reasons. For hospital/health centre the major reasons indicated are availability of qualified staff 93.4%, convenience 88.9% and availability of services 85.8%. On choice of TBAs place their reasons were cost 93.0%, availability 93.0% and convenience 81.4%. Reasons for using the church include availability 71.9%, labour starting at night 68.8% and charge low 62.5% while the major reason for delivering at home was that labour started at night 81.4%,  Use of birth attendants  during delivery  showed that   Nurse Midwives 70.6% is the highest and that there is reduction in the number of deliveries taken by the TBAS 15.0% and other people  compared with results  from other researchers. The women gave reasons which include: Provider knows her work, provider treats people with respect, the provider charges low and provider is always available as driving use of birth attendants during delivery.  Two hypotheses were formulated; (i) there is no significant difference in the use of birth attendants during delivery between primiparous and multiparous women. (ii) there is no significant difference between some women’s socio demographic characteristics (age, marital status, educational level of respondent and parity) on choice of birth place. Based on the findings there should be more campaigns for mothers to use the health facilities with skilled health personnel to avert maternal death. Health services should be made available 24hours for easy access; TBAS should undergo some training to equip them for management of simple cases.  Health services should be subsidized to reduce direct cost of health services on childbearing women.

CHAPTER ONE

INTRODUCTION

  Background to the Study

 The choice of birthplace and use birth attendant during delivery is very important for women and their families because it determines to a large extent the outcome of pregnancies and child births. Access to quality healthcare during pregnancy and in particular, during delivery is a crucial factor in explaining the huge disparity in maternal and perinatal morbidity and mortality between developing and the industrialized world. (Gayawan,2012)

Every year, 3.3 million babies are stillborn and maternal deaths have also continued unabated. More than half a million women die of pregnancy related complications with ninety-nine percent (99%) of these deaths occurring in developing regions particularly Africa and Asia.  (WHO 2005).  The implication is that every minute, at least a woman dies from pregnancy and childbirth in these regions. . Comparing with other regions of the world, the lifetime risk of maternal deaths in sub Saharan Africa is 1 in 22 mothers. North Africa has 1 in 210, 1 in 62 for Oceania, 1 in 120 for Asia, and 1in 290 for Latin America and the Caribbean (WHO, 2005).

According to the World Health Organization (WHO) (2005), the history of success in reducing maternal death and newborn mortalities show that skilled professional care during and after childbirth can make the difference between life and death for both women and their newborn babies.  The converse is true as well; a breakdown of access to skilled care may rapidly lead to increased unfavourable outcomes.  Yanagisawa, Oum and Wakai (2006), assert that obstetric complications are the leading cause of death among women of reproductive age in many developing countries. Globally, more than 200 million women become pregnant each year and 40% are estimated to experience pregnancy related health problems with 15% experiencing serious or long term complications and 1.7% developing fatal complications. The lifetime risk of deaths due to pregnancy related complications is 250 folds higher among women in developing countries. It is estimated that 88 – 98% of these deaths are avoidable and 70% are related to five direct obstetric complications:-  postpartum haemorrhage,   puerperal  pre –eclampsia and eclampsia, obstructed labour and abortion. AbouZahr, (2003) ; in Yanagisawa et al (2006) stated that   the prevention and management of these complications is the key to improving  maternal health. It is estimated that 97% of pregnant women in developed countries receive antenatal care ANC services and 99% use skilled obstetric services during delivery.  In developing countries, 65% and 53% of women use ANC and skilled obstetric care respectively (Uzochukwu, Onyeukwu and Okpala 2004.)  Acquiring the service of skilled attendants during delivery to improve the management of pregnancy and related complications is an effective means to reduce maternal mortality.

Iyaniwure and Yusuf (2009) observed that it is not enough to receive ANC  only. This is because majority of the complications that cause maternal death occur during or shortly after delivery.  It is therefore important that pregnant women have skilled obstetric attendance during delivery because pregnancy related complications are a leading cause of death among women of reproductive age in developing countries. According to joint WHO/UNFPA/UNICEF/World Bank statement(1999),skilled obstetric care or attendance refers to the process by which a pregnant woman and her infant are provided with adequate care during pregnancy, labour, birth, postpartum and immediate newborn period, whether the place of delivery is the home or hospital.  In order for this process to take place, the attendant must have the necessary skills and must be supported by an enabling environment at various levels of the healthcare system. For the world’s 60million non facility based births, addressing who is currently attending these births  and what effects they have on birth outcomes is a key starting point towards improving care during delivery.( Darmstadt et al 2009).                   

 A skilled birth attendant refers exclusively to people with midwifery skills (e.g. doctors, midwives, nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications.  They must be able to recognize  the onset of complications, perform essential interventions, start treatment and supervise the referral of mother and baby for interventions that are beyond their competence or not possible in a particular setting. 

In Nigeria,  the National HIV/AIDS and Reproductive Health Survey (2003) showed that 62% of women who gave birth   a   year before the study received ANC while 34% had skilled attendance during delivery. In Abia state, it was recorded that TBA’S attend to 80% of births and skilled midwives attend to 20% of births(Health statistics, 2012)   In developing countries, conditions are not favourable enough to encourage women living in rural and remote areas  to deliver at home. When home deliveries occur, some go well and others lead to complications and death . the later often occurs when the family is not prepared  to refer the woman  to a health facility  or cannot recognize the signs of  complications.

Barely 6 months to 2015 –  the year targeted for achieving the global reduction in maternal mortality, the continuing high rate of maternal mortality  remained worrisome. According to the United Nation’s and World Bank statistics an estimated 144 women die each  day in Nigeria from pregnancy related complications making her one of the worst countries for women to deliver babies in the world (Okeibunor, Onyeneho and Okonofua, 2010). The situation of maternal and child health in Nigeria is among the worst in Africa and has not improved substantially while  in some areas of the country, it has worsened over the past decade. The maternal mortality ratio ranges between 800-1,500 per 100,000 live births.  Nigeria is second to India in terms of absolute number of maternal deaths and regrettably despite abundant resources, contributes to more than 10% of all global maternal and under five deaths (NHS 2003 in Ladipo 2009).  Choice of birth place and birth attendants among childbearing women during delivery is very important for women and their families since this is a very critical period, a period when almost all the complications that bring about maternal morbidity and mortality occur.  Women need not die in childbirth; for optimum safety, every  pregnant woman without exception needs professional skilled care when giving birth.  This can avert, contain or mitigate many of the life threatening problems during childbirth and reduce maternal morbidity and mortality to a significant low level.  This study therefore intends to find out    the choice of birth place and  use of birth attendants during delivery  among women of child bearing age   in Akanu community of Ohafia L.G.A., Abia State.

Statement of Problem