CHAPTER ONE

INTRODUCTION

1.1       Background to the Study

Increasing women’s access to quality skilled attendant has become a focus of global efforts to realize the right of every woman to the best possible healthcare during pregnancy and childbirth (UNFPA, 2010). Several authors have postulate that skilled attendants during labour, delivery and in the early postpartum period can prevent up to 75% or more of maternal deaths (Harvey, 2004 et al; Koblinsky, Heichelheim 1999).

Use of a skilled attendant (doctor, nurse, or midwife) at birth is one of the recognized indicators for measuring progress towards the Millennium Development Goal 5, that is, reduction of maternal mortality ratio. Improving women’s health is the fifth Millennium Development Goal as adopted by heads of states in September 2000. The agreed target is to reduce, by 2015, maternal mortality in developing countries by 75% of the 1990 figure. (MDG)

Despite various national and international efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth the majority equally divided between Africa and Asia (Ronsmans, 2006). According to (Kowalewski, 2000) less than 1% of the pregnancy-related deaths occur in the more developed parts of the world, making maternal mortality the health indicator showing the greatest disparity between developing and developed countries. Despite the enhanced focus and awareness over the past decades, the situation in the poorest countries has not improved, and maternal mortality reduction is one of the explicit health millennium development goals.

Since the second half of the 20th century, the majority of births in the western world have taken place in hospital. Medicalisation of childbirth is a central feature in Western societies (Johanson, 2002). The majority of women living in high and middle-income countries have given birth in hospitals since the middle of the 20th century. However, there are regions where home birth is considered part of normal practice. The most cited case is The Netherlands where planned home birth is supported by the official healthcare system. Here, planned home birth is considered an appropriate choice for a woman of low risk and approximately 30% of all births take place at home (Hendrix 2009).

A significant proportion of mothers in developing countries still deliver at home unattended by skilled health workers (Montagu D, Yamey G, Visconti A, Harding A, Yoong J 2011). In diverse contexts, individual factors including maternal age, parity, education and marital status, household factors including family size, household wealth, and community factors including socioeconomic status, community health infrastructure, region, rural/urban residence, available health facilities, and distance to health facilities determine place of delivery and these factors interacting diverse ways in each context to determine place of delivery. In developing countries, pregnancy and childbirth are the leading causes of disability and death among women of reproductive age.

Indeed, the majority of maternal deaths occur either during or shortly after delivery. According to United Nations Children Fund (UNICEF 2009), pregnancy and childbirth related complications claim lives of at least 585,000 women every year in developing world. Pregnancy related problems include anemia, bleeding, infection, damage of the uterus, obstructed labor and abortion. Nearly all maternal deaths in developing countries occur among the vulnerable and disadvantaged population groups and yet most of these causes are preventable. Although the main causes of maternal mortality are well known and the knowledge as well as appropriate technology to reduce it has been available, maternal health problems are still highly prevalent in most African societies.

Statistics by (WHO 2010) found that 92% of women receive antenatal care from a trained health worker but when it comes to delivery time, most of them do not deliver at health units, but instead deliver elsewhere. It was estimated that about 15% of deliveries have complications that require skilled medical intervention. Yet only 53% of deliveries in developing countries take place with the assistance of a skilled birth attendant compared to 99% in developed countries. In resource-poor settings, home delivery is usually the cheapest option, but is associated with attendant risks of infection and lack of available equipment should complications occur. (Thind A. et al, 2008).

According to (Hogan, 2008), Ethiopia is among the top six high burden countries in which half of global maternal deaths occur, with an estimated maternal mortality ratio of 470 per 100, 000 live births. The most recent Ethiopian Demographic and Health Survey (EDHS 2011), very few mothers (34%) make at least one antenatal visit and even less receive delivery care from skilled birth attendants. It reports 28% of births were assisted by a traditional birth attendant (TBA) and 57 percent of births were assisted by a relative, or some other person.

In Kenya, maternal mortality rate has not reduced over recent years, and may even have increased from an estimated 380/100000 live births in 1990 to 530/100000 live births in 2008. Although a number of factors may have contributed to this, including improved identification of maternal deaths, health facility delivery remained low at44% and 42.6% in the early 1990s and in 2008 respectively. Recent evidence on determinants of place of delivery in Kenyan utilizing a nationally representative data and controlling for all factors is lacking, yet understanding the influences on place of delivery in Kenya is crucial to identifying key priority areas for policy and practice to increase the prevalence of skilled assisted deliveries(KDHS 2008).

Statistics by KDHS 2008 indicate that, 43 percent of births in Kenya are delivered in a health facility, while 56 percent of births take place at home. Traditional birth attendants continue to play a vital role in delivery, assisting with 28 percent of births (the same percentage as are assisted by nurses and midwives). Relatives and friends assist with 21 percent of births, and for 7 percent of births, mothers do not receive any form of assistance. Increasing the percentage of babies that are delivered in health facilities is an important factor in reducing the health risks to both the mother and the baby. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infection that can cause morbidity and mortality to either the mother or the baby (KDHS 2008).

Home deliveries in Kaloleni and Rabai districts of Kilifi County accounted for 65% of child birth by 2012 and there is not enough information in Kaloleni and Rabai to establish why these mothers still deliver at home despite concerted effort by the government and other stakeholders to encourage mother to deliver in health facilities (Mang’ong’o, 2013).

1.2       Statement of the Problem

Basing on the fact that various efforts have been put in place by the Government of Kenya, through free maternity services to increase the percentage of mothers who deliver from the health facility under the assistance of a skilled health worker, the majority of mothers still deliver at home without skilled birth attendants. Statistics by the District Health information System (DHIS) indicate that only 36% of births in Kenya are attended by a skilled birth attendant. This is way too far the targets set at the International Conference on Population and Development(ICPD) whose goal is to have more than 80% of deliveries assisted by skilled attendants globally by 2005, 85% by 2010 and 90% by 2015 (UNFPA 2010).

Home deliveries are poorly managed and inadequate care is offered during the critical hours of a woman’s life. This exposes the mother and the baby to health risks and complications which include anemia, bleeding, infection and if immediate interventions are not taken this can lead to death or damage of the reproductive organs. It is evident from reports that every day, almost 800 women die in pregnancy or childbirth worldwide. Evidence shows that infants whose mothers die are more likely to die before reaching their second birthday than infants whose mothers survive. And for every woman who dies, 20 or more experience serious complications (UNFPA 2010).

Maternal health services have been improved upon in all the health centers in Enugu State. However, many women do not utilize these facilities and instead seek delivery care from high risk places. Giving birth without the assistance of a skilled birth attendant can pose life threatening situations incase complications occur during the process. This study, therefore, was set to investigate determinants of child bearing women’s choice health care in Enugu State.

1.3       Purpose of the Study

The purpose of this study was to investigate determinants of child bearing women’s choice health care in Enugu State. The purpose of the study was achieved through the following specific objectives:

1. To determine how demographic factors influence the choice of place of delivery among women in Enugu State.
2. To establish how socio cultural factors influence the choice of place of delivery among women in Enugu State.
3. To examine the influence of economic factors on the choice of place of delivery among women in Enugu State.
4. To establish how Antenatal Clinic attendance influences the choice of place of delivery among women in Enugu State.

1.4       Research Questions

The study sought to answer the following questions;

1. To what extend do demographic factors influence the choice of place of delivery among women in Enugu State?
2. How do socio cultural factors influence the choice of place of delivery among women in Enugu State?
3. To what extend do economic factors influence the choice of place of delivery among women in Enugu State?
4. To what extent does Antenatal Clinic attendance influence the choice of place of delivery among women in Enugu State?

1.5       Significance of the study

The findings of this study may have both theoretical and practical implications for the future of suitability of place of delivery in Enugu State. Theoretically, the study may contribute to the advancement of knowledge about factors determining the choice of place of delivery in Enugu State. The study might also have practical significance in that, it may assist in determining the level of utilization of SBAs and TBAs at birth. The findings may be of immediate benefit to the Ministry of Health in the formulation of future public health policies aimed at integrating TBAs in the health system as agents of change to enhance places of delivery. Similarly, results of this study may enlighten the public especially mothers and spouses on the importance of considering a suitable and safe place of delivery. In addition, this can lead to appropriate interventions by non-governmental organizations and other key stakeholders that have established or intend to establish reproductive health programs. The study may also forms a base on which others can develop their studies based on the gaps identified.

1.6       Limitations of the Study

The limitations of the study were; inadequate time to collect data, therefore two research assistants were hired to assist in carrying out the task.

Cases of respondents not cooperating were experienced and even some had to withdraw from the exercise after answering some questions because they were not convinced if the study was done for genuine reasons.

1.7       Delimitations of the study

The study was carried in Enugu State leaving out other states in the county. The findings of the study may not be generalized to an urban setup since majority of mothers with challenges in choice of place of delivery are mainly in rural set up.

The study also focused on women of childbearing age in Enugu state only. The findings therefore may not be generalized to the entire women in the county. Future researchers are encouraged to do further research in this area.

1.8       Definition of Terms

Women: This refers to all females of reproductive age that is, 15 years to 49 years of age.

Choice of place of delivery: This is the preferred option by the women who are giving birth; it could either be home, health facility or assisted by traditional birth attendant.

Marital status: This refers to whether a person is married, single, divorced or widowed.

Level of education: This refers to the level of schooling a person has reached, that is, primary education, secondary or tertiary education.

Antenatal Care: This entails the care that is given to women who are expectant or pregnant.