DETERMINANTS OF CHILD BEARING WOMEN'S CHOICE OF HEALTH CARE

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Ensuring universal access to quality maternal healthcare remains one of the foremost priorities of global health policy. The right of every woman to receive the best possible care during pregnancy and childbirth has been enshrined in several international frameworks, most recently the Sustainable Development Goals (SDGs), which under SDG Target 3.1 call for a reduction of the global maternal mortality ratio (MMR) to fewer than 70 deaths per 100,000 live births by 2030 (United Nations Department of Economic and Social Affairs [UN DESA], 2024). The availability and utilisation of skilled birth attendants (SBAs) comprising qualified doctors, nurses, and midwives is one of the most effective levers for reducing maternal mortality, as complications arising during labour and the immediate postpartum period can be promptly identified and managed only when skilled personnel are present (Mohammed et al., 2022; World Health Organization [WHO], 2023).

Despite decades of coordinated international effort, maternal mortality remains unacceptably high. According to the WHO, approximately 260,000 women died during or following pregnancy and childbirth in 2023, with about 92% of all maternal deaths occurring in low- and lower-middle-income countries (WHO, 2023). Sub-Saharan Africa and Southern Asia jointly accounted for around 87% of the estimated global maternal deaths in 2023, with Sub-Saharan Africa alone responsible for approximately 70% or 182,000 deaths (WHO, 2023; UNICEF, 2024). While the global MMR declined by 40% between 2000 and 2023 (from 328 to 197 deaths per 100,000 live births), this trajectory remains far too slow to meet the 2030 SDG target, which would require an annual reduction rate of nearly 15% between 2024 and 2030 (UNICEF, 2024; UN DESA, 2024).

The proportion of births attended by skilled health personnel has risen globally, from 80% in 2015 to approximately 87% in 2024. However, stark regional disparities persist: in Sub-Saharan Africa, only 73% of births were attended by skilled personnel in 2023 the lowest rate globally compared with 96% in Eastern and South-Eastern Asia (UN DESA, 2024; United Nations Statistics Division, 2024). As of 2023, approximately 18 million births still occurred without skilled assistance worldwide (UN DESA, 2024). These figures underscore the persistent gap between global aspirations and ground-level realities, particularly in low-income settings where most births still occur at home without any trained health worker present.

In sub-Saharan Africa, a significant proportion of mothers continue to deliver at home, unattended by skilled health workers. Research drawing on recent Demographic and Health Survey (DHS) data from 22 sub-Saharan African countries found that even among women with easy access to health facilities, a large proportion still chose to deliver at home (Tekeba et al., 2025). Women above 35 years of age, those residing in rural areas, those in the poorest wealth quintiles, and those with limited autonomy in household health decisions were significantly more likely to opt for home delivery (Tekeba et al., 2025; Regassa et al., 2022). Conversely, women with higher levels of education, those who attended four or more antenatal care (ANC) visits, and those covered by health insurance had significantly reduced odds of home delivery (Tekeba et al., 2025; Zegeye et al., 2023). These findings point to a complex interplay of individual, household, and community-level factors that shape women's delivery choices, and reinforce the need for context-specific, evidence-based interventions.

The medicalisation of childbirth has become a defining feature of high- and middle-income countries, where the vast majority of births now occur in health facilities staffed by trained professionals. However, in many low-income and rural settings, particularly across sub-Saharan Africa, traditional birth attendants (TBAs) and informal providers remain central to childbirth care. Recent systematic evidence from sub-Saharan Africa shows that the utilisation of antenatal care (ANC) and skilled birth delivery (SBD) services remains suboptimal: only 70.6% of women across the region delivered with a skilled birth attendant, and only 40.7% accessed postnatal care (Imo et al., 2024). This mismatch between ANC attendance and institutional delivery sometimes referred to as the "last-mile gap" is a critical concern, as most maternal deaths occur during or within 24 hours after delivery due to haemorrhage, hypertension, ruptured uterus, and sepsis (Mohammed et al., 2022; Teressa et al., 2024).

In Nigeria, the context is particularly alarming. Nigeria bears a disproportionately high burden of global maternal mortality, accounting for approximately 82,000 deaths in 2020 alone more than a quarter (28.5%) of all estimated global maternal deaths that year (Ekele et al., 2023; Osaji et al., 2023). The national MMR stands at approximately 814 per 100,000 live births, with a lifetime risk of maternal death of 1 in 22 for Nigerian women, compared to 1 in 4,900 in high-income countries (Osaji et al., 2023). Low rates of institutional delivery, poor uptake of ANC services, and deep-rooted socio-cultural and economic barriers together sustain this tragic burden. Studies examining health facility delivery in Nigeria have consistently identified women's educational attainment, household wealth, ANC attendance, place of residence (urban versus rural), parity, and health insurance coverage as key determinants of whether women choose to deliver in a health facility or at home (Olakunde et al., 2023; Ogunyemi et al., 2024; Okeke et al., 2025).

In Enugu State, south-east Nigeria, studies have documented rural-urban disparities in birth preparedness and complication readiness among pregnant women, pointing to the inadequate translation of ANC attendance into institutional delivery (Obionu et al., 2022). Research among women in Ebonyi State, which borders Enugu, found that distance to health facilities, fears about being attended by male providers, cost of services, and preference for TBAs were significant drivers of home delivery (Opara et al., 2024). A 2025 study specifically examining demand and supply factors associated with women's preferences for delivery locations in rural and urban communities of Enugu State identified unique patterns of utilisation linked to facility quality, attitude of health workers, proximity, and cultural beliefs (Okeke et al., 2025). These contextual findings underscore the importance of studying local determinants of delivery choices to inform effective policy design.

Barriers to healthcare access in sub-Saharan Africa extend well beyond geography. A pooled analysis of multi-country DHS data from 2019 to 2023, covering a weighted sample of 134,470 women of reproductive age in Sub-Saharan Africa, found that over 55% of women encountered significant barriers to healthcare access (Gebre et al., 2025). Key determinants included wealth index, media exposure, ANC attendance, health insurance coverage, husband's educational status, community poverty levels, and community literacy levels (Gebre et al., 2025). The influence of cultural and religious structures in shaping health-seeking behaviour has also been well-documented. In Kogi State, Nigeria, a focused ethnographic study among Igala women identified male skilled attendants' presence, the attitude of health workers, high cost of services, limited facility hours, lack of awareness of maternal health services, and poor infrastructure as both facilitating and limiting factors in the use of primary health facilities (Opara et al., 2024). These findings resonate with the wider literature on cultural determinants of maternal healthcare utilisation across sub-Saharan Africa.

Machine-learning analyses of large-scale DHS datasets have further illuminated factors predicting place of delivery in East Africa. A 2024 study employing advanced machine learning techniques found that rural residence, lack of decision-making autonomy, lower wealth status, and low ANC utilisation were the most consistent predictors of home delivery across East African countries (Ngusie et al., 2024). A case-control study conducted in Bore District, Ethiopia, in 2022 similarly identified distance to health facility, poor ANC follow-up, negative perceptions of health facility care, and lack of birth preparedness as key determinants of home delivery among reproductive-age women (Teressa et al., 2024). These multi-country and country-specific findings, while not directly transferable to Enugu State, provide a robust conceptual framework for understanding how demand- and supply-side factors combine to determine place of delivery in low-resource settings.

It is within this global and national context that the present study is situated. Despite improvements in the availability of maternal health services across Enugu State's health facilities, many women continue to bypass these services and deliver at home or with unskilled attendants, exposing themselves and their newborns to preventable risks. Understanding the demographic, socio-cultural, economic, and healthcare-related determinants of women's choice of place of delivery is therefore essential for designing targeted and effective interventions that can meaningfully reduce maternal and neonatal mortality in Enugu State.

1.2 Statement of the Problem

Despite sustained national and global efforts to reduce maternal mortality through improved access to skilled birth attendants and institutional delivery services, a significant proportion of women in Enugu State continue to deliver outside health facilities. Nigeria's maternal mortality ratio of approximately 814 per 100,000 live births remains among the highest in the world, with institutional delivery rates failing to reflect the investment in maternal health infrastructure (Osaji et al., 2023). The Nigeria Demographic and Health Survey (NDHS) and subsequent studies indicate that the majority of births in rural areas of South-East Nigeria still take place at home or with TBAs, not in health facilities supervised by trained professionals (Olakunde et al., 2023; Okeke et al., 2025).

Home deliveries, when managed without skilled personnel, expose mothers and newborns to life-threatening risks, including haemorrhage, puerperal sepsis, obstructed labour, eclampsia, and birth asphyxia all of which require prompt, skilled intervention to prevent death or permanent disability (Teressa et al., 2024; WHO, 2023). For every woman who dies from a pregnancy-related complication, an estimated 20 or more suffer severe morbidity; infants whose mothers die in childbirth are also significantly more likely to die before their second birthday (UNICEF, 2024). The personal, familial, and societal costs of preventable maternal and neonatal deaths are immense.

Recent evidence from Enugu State highlights a persistent mismatch between women's engagement with antenatal care services and their ultimate choice of delivery location (Obionu et al., 2022; Okeke et al., 2025). Focused antenatal care (FANC) assessment studies conducted at tertiary hospitals in Enugu found that while some women access ANC services, uptake remains suboptimal and does not consistently translate into institutional delivery (Osaji et al., 2023). This gap reflects the operation of factors beyond mere geographical access, including socio-cultural beliefs, perceived costs, attitudes of health workers, household decision-making dynamics, and women's autonomy all of which mediate the pathway from healthcare contact to institutional delivery (Opara et al., 2024; Gebre et al., 2025).

Although some studies have examined place of delivery in Nigeria and its South-East geopolitical zone, rigorous, recent, and locally specific evidence on the determinants of childbearing women's choice of healthcare in Enugu State remains limited. Without a clear, evidence-based understanding of why women in Enugu State make the delivery choices they do, policy-makers, health managers, and practitioners are constrained in their ability to design targeted, effective interventions. This study was therefore designed to fill that gap by comprehensively investigating the demographic, socio-cultural, economic, and ANC-related determinants of childbearing women's choice of healthcare (specifically, place of delivery) in Enugu State, Nigeria.

1.3 Purpose of the Study

The primary purpose of this study is to investigate the determinants of childbearing women's choice of healthcare with specific reference to their preferred place of delivery in Enugu State, Nigeria. This overarching objective is achieved through the following specific aims:

1. To determine how demographic factors (including age, parity, educational level, and marital status) influence the choice of place of delivery among childbearing women in Enugu State.

2. To establish how socio-cultural factors (including cultural beliefs, influence of family members, role of TBAs, and religious considerations) shape the choice of place of delivery among childbearing women in Enugu State.

3. To examine the influence of economic factors (including household wealth, cost of maternal health services, health insurance coverage, and women's financial autonomy) on the choice of place of delivery among childbearing women in Enugu State.

4. To establish how antenatal clinic (ANC) attendance, including frequency of visits, quality of ANC education received, and birth preparedness counselling, influences the choice of place of delivery among childbearing women in Enugu State.

1.4 Research Questions

The study sought to answer the following research questions:

1. To what extent do demographic factors influence the choice of place of delivery among childbearing women in Enugu State?

2. How do socio-cultural factors influence the choice of place of delivery among childbearing women in Enugu State?

3. To what extent do economic factors influence the choice of place of delivery among childbearing women in Enugu State?

4. To what extent does antenatal clinic (ANC) attendance influence the choice of place of delivery among childbearing women in Enugu State?

1.5 Significance of the Study

This study carries both theoretical and practical significance at multiple levels. Theoretically, it contributes to the growing body of evidence on the determinants of maternal healthcare utilisation in low-resource settings, particularly within the Nigerian context. By systematically examining demographic, socio-cultural, economic, and ANC-related factors as a combined framework, the study advances understanding of how these dimensions interact to shape women's delivery choices in Enugu State a topic that has received limited focused scholarly attention in recent years (Okeke et al., 2025; Obionu et al., 2022).

Practically, the findings of this study are expected to provide actionable intelligence for several stakeholders. The Enugu State Ministry of Health and the Federal Ministry of Health can utilise the evidence to refine public health policies and programmes aimed at increasing institutional delivery rates and skilled birth attendance. In particular, the study's findings on the role of TBAs can inform strategies for better integrating TBAs into the formal healthcare system as agents of referral and health promotion, consistent with evidence-based recommendations for improving the continuum of maternal care in low-resource settings (Imo et al., 2024; Opara et al., 2024). The study also has relevance for non-governmental organisations (NGOs) and development partners implementing reproductive health programmes in Enugu State, as it can help identify high-risk sub-populations such as rural, less-educated, and lower-wealth-quintile women for targeted outreach and support.

The study also has broader implications for public awareness and community-level change. By documenting and disseminating findings to communities, women's groups, and community leaders in Enugu State, it can contribute to shifting perceptions about the importance of skilled birth attendance and help dispel myths and misconceptions that sustain harmful birthing practices. Furthermore, the study constitutes a baseline of evidence upon which future researchers can build, addressing identified gaps and tracking changes in women's delivery preferences over time as interventions are scaled up in Enugu State.

1.6 Limitations of the Study

This study was subject to several limitations. First, constraints on time and resources necessitated the use of research assistants for data collection, which may have introduced some variability in the quality and consistency of data gathered across different communities. Extensive training and standardised protocols were employed to minimise this risk.

Second, some respondents were initially unwilling to participate or withdrew partway through the study, concerned about the purposes for which the data would be used. Ethical reassurances, informed consent procedures, and explanations of the study's academic and public-health purposes were provided to minimise non-participation, though some dropout could not be entirely avoided.

Third, the study relied primarily on self-reported data, which may be susceptible to social desirability bias, particularly with respect to sensitive topics such as cultural beliefs and household decision-making dynamics. Recall bias is also possible where questions about past pregnancies and deliveries were included.

Finally, cross-sectional study designs, while well-suited to determining prevalence and associations, do not establish causality. The findings therefore reflect correlations between variables rather than definitive causal relationships. Notwithstanding these limitations, the study provides valuable and timely evidence on a critical public health concern.

1.7 Delimitations of the Study

The scope of this study is delimited in several important ways. Geographically, the study is restricted to Enugu State, Nigeria, and its findings cannot be generalised to other states or regions of the country without further research. The focus on Enugu State was deliberate, given the relative paucity of recent, locally specific evidence on determinants of delivery choices in the state, and the necessity of understanding context-specific dynamics (Okeke et al., 2025).

In terms of population, the study focused exclusively on women of childbearing age (15–49 years) residing in Enugu State who had a recent birth experience. The findings are therefore not directly generalisable to the broader female population or to women in other life stages. Similarly, while the study encompasses both rural and urban settings within Enugu State, it is acknowledged that the challenges and determinants of delivery choices are likely to be more pronounced in rural communities, given documented rural-urban disparities in access to maternal health services (Obionu et al., 2022; Gebre et al., 2025). Future researchers are encouraged to conduct comparative studies across multiple states and to explore qualitative dimensions of women's delivery choices to complement and deepen the findings of this study.

1.8 Definition of Terms

Women of Childbearing Age: Refers to all females within the reproductive age bracket of 15 to 49 years, as commonly defined in demographic and health surveys in developing countries.

Choice of Place of Delivery: Refers to the location selected or preferred by a woman for giving birth. This may include a public or private health facility, a TBA's premises, or the woman's own home. The choice encompasses the woman's own preferences as well as those shaped by family members, cultural norms, economic circumstances, and perceived quality of available options.

Skilled Birth Attendant (SBA): As defined by the World Health Organization (2023), an SBA is a competent maternal and newborn health professional including doctors, nurses, and midwives who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns.

Traditional Birth Attendant (TBA): A person who assists the mother at childbirth and who initially acquired her skills by delivering babies herself or through an informal apprenticeship to other TBAs. TBAs are distinct from skilled birth attendants and typically operate within community settings, often guided by cultural traditions and local knowledge.

Antenatal Care (ANC): The care and services provided to women during pregnancy by qualified health professionals, including clinical assessment, health education, iron and folic acid supplementation, screening for and management of pregnancy-related complications, and birth preparedness counselling. The WHO recommends a minimum of eight ANC contacts for a positive pregnancy experience.

Marital Status: Refers to the legally or socially recognised status of an individual in relation to a partner, including married, single (never married), widowed, separated, or divorced.

Level of Education: Refers to the highest formal educational qualification attained by an individual, broadly categorised as no formal education, primary education, secondary education, or tertiary (higher) education. Educational level has been consistently identified as one of the most powerful determinants of maternal health service utilisation across sub-Saharan Africa (Tekeba et al., 2025; Ngusie et al., 2024).

Institutional Delivery: Refers to childbirth that takes place in a recognised health facility whether public (primary health centre, general hospital, teaching hospital) or private (clinic, maternity home) under the supervision of trained health personnel.

Home Delivery: Refers to childbirth occurring outside a formal health facility, typically in the woman's own home or that of a family member, and often with assistance from a TBA, a relative, or with no skilled attendant at all. Home delivery is a major contributor to maternal and neonatal mortality in low-resource settings, owing to the absence of essential equipment and the inability to manage obstetric emergencies (Teressa et al., 2024; WHO, 2023).

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