Critical Care Obstetrics and Gynecology

Keywords

4D sonography; Facility delivery; Reproductive-age women; Low-resource setting

Introduction

In the last decade, the management of obstructed labor, incomplete miscarriage, single or multiple pregnancies, molar pregnancy, ectopic pregnancy, placenta previa, fetal abnormality, intrauterine growth restriction, and other obstetric complication has been markedly improved with ultrasound [1,2]. Unfortunately, the availability and quality of ultrasound service in developing countries are generally poor [3,4]. Ultrasound is operator dependent and significantly effective in the provision of exceptional care by trained personnel [5]. However, there is still a lack of standardized training for ultrasound in obstetrics and gynecology [6]. With the advent of modern ultrasound such as 4D imaging, the use of ultrasound as entertainment or for non-medical purposes is alarming; this pattern of use is therefore discouraged by governments and professional bodies [7]. Numerous advantages of 4D (sonographic tomography) over conventional 2D ultrasonography are but not limited to; less dependency on the operator, a reduction in scanning time, and the chance of standardizing the entire process of performing the obstetric examination [8,9]. Although ultrasound has been widely used in the management in obstetrics, uncertainties arise from its safety, increasing calls for its prudent use and strict adherence to the ALARA (As Low As Reasonably Achievable) principle [10,11]. The place of delivery is a decisive factor that affects the health and wellbeing of the mother and newborn. Institutional deliveries essentially help women to access skilled assistance, drugs, equipment, and referral transport [12]. The provision of qualitative care in a woman’s approved place of delivery ensures early detection and prompt management of abnormalities thus reducing complications [12]. A newfangled demographic and health survey revealed that living in urban areas, being wealthy, more educated, availability of optimal Antenatal Care (ANC) services, and lower parity strongly predicted where women delivered [13]. Other studies revealed that education, family size, and residence were important predictors of a place of delivery [14,15]. Some of the factors associated with institutional delivery were four or more ANC, birth order, age at last delivery, and duration of labor [16-18]. Most women deliver at home in developing countries and the identified reasons for the non-utilization of obstetric services to include but not limited to: financial constraints, lack of awareness of maternity waiting homes, no perceived need for such services, and preference for home delivery [19,20]. Despite the existing national programs for improving maternal and child health in Nigeria [21], maternal mortality and morbidity are on the increase and studies proposed that the preponderance of maternal deaths can be curbed or reduced if women had access to maternal health facilities during pregnancy, childbirth and the first month after delivery [22,23]. In Nigeria presently, maternal health is incapable of achieving a sustainable development due to poverty, corruption, misplaced priority, and neo-liberal policies currently resulting in socio-economic dislocation of families [23]. The biased distribution pattern of health facilities in favor of urban areas also reflects the utilization rate of health facilities by rural dwellers mostly constrained by distance to urban areas [21,23,24]. The majorities of obstetric complications usually occur at the time of delivery and cannot be predicted [16,25]. Consequently, all pregnant women must have access to a skilled attendant, someone with midwifery skills who can identify and manage obstetric complications, or refer in time if needed [26]. Skilled attendance at delivery is recommended as the single most important factor in preventing maternal deaths, stillbirths and improving newborn survival [26,27].

Material and Methods

Study settings and design

Surulere Local Government Area in Lagos State (mainland of Lagos), is known for its residential and commercial status having a population of 503,975 inhabitants (260,509 males and 242,356 females) in 2006 census. The population of women of the reproductive age group of 15-49 years is 48,020 which make up 10% of the total population [28]. The health facilities available at Surulere Local Government include; General Hospital Randle, Mother and Child Centre, Gbaja; Havana and Parkland Hospitals, and several Primary Healthcare Centers.

Data collection tools and procedure

The survey was conducted between July and November, 2019. The questionnaire was made up of an open and closed-ended question, interviews were granted to extract data from the respondents. Questions were divided into 3 sections. Section A: Socio-demographic data of the respondents, Section B: Reasons for the choice of place of delivery at last pregnancy and Section C: Pattern of the utilization of the places of delivery. The instrument was developed using study objectives and a review of the findings of comparative study [29]. For aptness and explicability of the population studied, a pilot study was done by administering the questionnaire to thirty-eight (38) women of reproductive age who have had at least one delivery, in another local government close by (Coker/Aguda Local Council Development Area). Responses from these were used to make adjustments and corrections before the final data collection was done.

Sample size determination and sampling procedures

Cochran formula n0=z2pq/d2 was used to estimate the sample size, with the following assumptions deduced while calculating the sample size. The degree of accuracy (d) was set at 0.05 with the interval (z) set at 1.96% (z=1.96). The estimated prevalence, p=0.05 and q=0.5. This gave a sample size of 385. These comprised of women of reproductive age group (15-49 years), who have had at least one delivery, in the last five years and gave consent (inclusion criteria). A multistage sampling technique was adopted to select 385 reproductive-aged women from the study area. Out of 12 wards in Surulere Local Government Area, simple random sampling was used to select five (5) wards. At each selected ward, simple random sampling was equally used to select one street per ward making it a total of five streets. From the streets, the starting point of the houses was determined by balloting. Other houses were selected systematically using an interval of 5. At the houses selected, the administration of questionnaires was done to respondents that fulfill the inclusion criteria.

Data analysis

Information obtained through the questionnaire, and the interview was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Frequencies and percentages were presented as tables. Statistically significant differences (p<0.05) were identified using a chi-square test analysis.

Ethical consideration

Ethical approvals were not sought because the standard confidentiality policies were not employed in this research project. Items seeking personal information (name, phone number, address, etc.) were not included in the questionnaire to promote privacy and confidentiality.

Result

Among 385 respondents, the mean age of the respondent was 31.52 ± 0.3 years. Most respondents with a total of 337 (87.5%) were married. The majority 205 (53.2%) had 3-4 children and 86.2% of the household were headed by their husbands, 43.4% of these husbands have tertiary education. The respondents with children of 5 and above (54.3%) were predominant (Table 1). Respondents who are Christians made up 54.3%, 26% are Muslims, 14% are traditionalists and 5.7% are worshippers of other beliefs. 87.5% of the respondents were married. 3.4% were single, 3.1% divorced, 2.6% separated and 3.4% widowed. Among the respondents, 49.9% were Yorubas, 24.4% Igbos, 4.7% Hausas and 21% from other minor ethnic groups. The educational qualification of the respondents showed that 1.6% had no formal education, 8.6% had primary education, 44.7% had secondary education and 45.2% had tertiary education (Table 1). About 25 women did not attend ANC in their last confinement due to limited time (1.6%), insufficient finance (3.1%), and complaint of proximity to their homes (1.8%). Family income greater than or equal to â?¦ 200, 000.00 (550 USD) made up 53.5% of respondents (Table 1).

Table 1: Demographic characteristics of the respondents.

Fewer respondents (40.8%) would choose the place of delivery in the last pregnancy due to the availability of modern 4D ultrasound equipment (Table 2).

Table 2: Respondents’ reasons for choosing place of delivery in last pregnancy.

Respondents mostly delivered in private hospitals, while a few favored the services of traditional birth Attendants and church facilities. Postnatal care was received by 54.5% of respondents and these occurred mostly in the first and trimester (35.6% and 32.7%). Among the 385 women, 67.5% of respondents rated the services rendered in their place of delivery as worse, while 32.5% said the place of delivery was the best. Regarding willingness to utilize the place again, 52.5% were willing, while 47.5% were not willing. Also, 40.3% were willing to recommend the place to their family/friends while 59.7% were not willing (Table 3).

Table 3: Respondents’ rate and pattern of utilization.

Although the respondents’ religion (p>0.05) and marital status (p>0.05), did not influence their place of delivery. The age of respondents (p<0.05), educational status (p<0.05), occupation (p<0.05), parity (p<0.05), ethnicity (p<0.05), family income (p<0.05), husbands’ education (p<0.05) and registration for ANC status (p<0.05) were associated with their place of delivery (Table 4).

Table 4: Association between socio-demographic characteristics and place of delivery (n=385).

Discussion

This study highlights important determinants of place of delivery among women of reproductive age. Knowledge of significant determinants may help formulate public health policies geared towards reducing maternal and perinatal mortality. The use of obstetric ultrasound as a surveillance method has been assumed to be the best means of monitoring of the fetus during and before labor. It effectively gives adequate information about fetal wellbeing than the specifically used cardiotocogram [30], or symphysis-fundal height measurement which is deficient in obese expectant mothers [31]. In comparison to 2D ultrasound, 4D ultrasound provides a real-time assessment of the face, mouth, eyes, swallowing direction of fetal movements, and breathing movements. The pattern of fetal behavior for each trimester of pregnancy can be easily understood after 15-20 minutes of the 4D ultrasound examination [32]. The present study showed that only 40.8% of respondents would choose the place of delivery in the last pregnancy with or without a 4D ultrasound unit. These findings suggest an associated poor satisfactory outcome from the obstetric ultrasound in comparison to 75% in Bauchi [33], and with an average satisfaction in 53% of respondents in Enugu [34]. A cogent explanation to these differences is that the dense population in Lagos might have overburdened the sonographers and radiologists with high patient load, thus increasing the client’s waiting time or the effect of poor communication of sonographic findings to clients.

Factors influencing facility delivery

In the present study, marital status and religion had no statistically significant influence on the place of delivery (p>0.05), similar to another study in North-west Nigeria [35], on the other hand, a quantitative study by Al-Mujtaba et al. [36], concluded that barriers to the uptake of maternal health services are minimally impacted by religion. We do, however, concede that there is a chance that our study is influenced by the homogeneity of the respondents. Ethnicity in the present study had a significant influence on the place of delivery similar to other studies [18,37-40]. Maternal education is one of the most important determinants for health service use. It is tenable that bettereducated women are more aware of health problems, know more about the availability of health care services, and use this information more effectively to maintain or achieve good health status. In this study, the level of education of women was found to be a statistically significant determinant of the place of delivery. These findings are identical to other studies [15,41- 44], and surprisingly different from a study by Yahya et al. [45]. A study in Jos, Nigeria found that the majority of the women who had no formal education and those with primary education opted for home delivery [46]. Husband’s education and women with husbands who have tertiary education were likely to utilize health facilities than those with a lower level of education, due to their better understanding of the increased risk associated with home delivery. This is in agreement with another study [47] but disagrees with a study in Eritea [48].

ANC services give opportunities for health experts to promote a specific place of delivery or offer women information on the status of their pregnancy, this condition expedites their decisions on where to deliver. Early booking of ANC is important as it provides health workers with the opportunity of early detection of the maternal problem and corrective measures are taken to obviate them for the benefit of mother and fetus. The present study showed a significant relationship between respondent's registration for ANC and their choice of place of delivery. Although fewer respondents did not utilize the ANC (6.5%), it is plausible to say that patient’s neglect could lead to poor management outcomes. However, these respondents stated the lack of sufficient funds, no time, and far distance as reasons for the non-attendance of ANC, indistinguishable from previous studies [15,18,26]. Women with a combined family income greater than â?¦ 200, 000.00 (550 USD) made up 90.8%. The relationship between occupation and a higher combined family income of respondents and health facility delivery was statistically significant. Our findings are consistent with other studies [43,48,49]. Also women with a higher number of children and larger family size were more likely to opt for facility delivery. This is identical to a study by Abimbola et al. [50]. However, a study by Kifle et al. [48]. suggested that women with a higher number of children would have an unmet need of contraception which influenced negatively on their choice of facility delivery.

In our study, the majority of the respondents were 25-31 years of age who delivered in a health facility similar to a study in Uganda [51], and incongruent with other studies [29,46]. The respondents who delivered in a health facility within the last five years were 85.7%. This is similar to a percentage of 88.3% described in a community-based cross-sectional Ethiopian study carried out in an urban setting [29,52] in contrast with another study in Ethiopia carried out in a rural setting that reported that 26.9% of deliveries took place in a health facility [19]. A plausible explanation would be that women living in urban settings are more knowledgeable of the benefits of health facility delivery than their rural counterparts. Urban dwellers show an increased probability to be affluent; affluence is an important determinant of facility delivery in developing countries [18]. Further in this study, 54.5% of the women received postnatal care in their last place of delivery. This high level of satisfaction expressed by respondents was majorly due to the efficiency of service rendered (10.6%), affordability (10.1%), and neatness (4.4%) among others. Numerous studies [15,29], however, reported staff attitude, long waiting time, and cost of services as reasons for establishing their place of delivery as the best for delivery, their indices are consistent to this present study. Finally, more than half (52.5%) of the women showed willingness in using the place for delivery again with 40.3% ready to recommend the place to a friend and/ or family member.

Study limitations

There is a possibility of recall bias in the study; some of the respondents might have been unable to accurately recall the information needed in the study. The magnitude of these chances of biases could not be directly and easily established.

Conclusion

Maternal health care services provided by well trained and equipped health workers are widely recognized as an important protective factor against maternal morbidity and mortality. The role of advanced ultrasound equipment is indispensable in the management of obstetric complications. Yet, the availability of this 4D ultrasound in hospitals does not influence the majority of the client’s choice. In the Surulere area of Lagos among the study participants, 85.7% utilized health facility and 14.3% non-health facility for deliveries in the last five years. There were statistically significant associations between women’s age, education, occupation, parity, family income, husbands’ education, ethnicity, and choice of place of delivery. There were no significant associations between marital status, religion, and choice of place of delivery. Thus, health authorities and policymakers should provide community-based health education, awareness creation, and improve better access to information for mothers regarding maternal institutional delivery. Also, maternal health services need to continuously sensitize the community so that the number of pregnant mothers delivered in a health facility is increased even further.

References

1. Groen RS, Leow JJ, Sadasivam V, Kushner AL (2011) Indications for ultrasound use in low�and middle�income countries. Trop Med Int Health 16: 1525-1535.
2. Kim ET, Singh K, Moran A, Armbruster D, Kozuki N (2018) Obstetric ultrasound use in low and middle income countries: a narrative review. Reprod Health 15: 129.
3. Bamidele AR, Hoque ME, Van der Heever H (2011) Patient satisfaction and factor of importance in primary health Care Services in Botswana. Afr J Biomed Res 14: 1-7.
4. Shah S, Bellows BA, Adedipe AA, Totten JE, Backlund BH, et al. (2015) Perceived barriers in the use of ultrasound in developing countries. Crit Ultrasound J 7: 1-5.
5. Vrachnis N, Papageorghiou AT, Bilardo CM, Abuhamad A, Tabor A, et al. (2019) International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)-the propagation of knowledge in ultrasound for the improvement of OB/GYN care worldwide: experience of basic ultrasound training in Oman. BMC Med Educ 19: 434.
6. Leonardi M, Murji A, D'Souza R (2018) Ultrasound curricula in obstetrics and gynecology training programs. Ultrasound Obst Gyn 52: 147-150.
7. Leung JLY, Pang SMC (2009) Ethical analysis of non-medical fetal ultrasound. Nurs Ethics 16: 637-646.
8. Benacerraf BR, Shipp TD, Bromley B (2006) Three-dimensional US of the fetus: volume imaging. Radiology 238: 988-996.
9. Gonçalves LF, Nien JK, Espinoza J, Kusanovic JP, Lee W, et al. (2006) What does 2â?dimensional imaging add to 3â?and 4â?dimensional obstetric ultrasonography? J Ultrasound Med 25: 691-699.
10. Torloni MR, Vedmedovska N, Merialdi M, Betran AP, Allen T, et al. (2009) Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta�analysis. Ultrasound Obst Gyn 33: 599-608.
11. Abramowicz JS (2016) Ultrasound in the first trimester and earlier: how to keep it safe. In First-Trimester Ultrasound, Springer, Cham : 1-19.
12. Eluwa GI, Adebajo SB, Torpey K, Shittu O, Abdu-Aguye S, et al. (2018) The effects of centering pregnancy on maternal and fetal outcomes in northern Nigeria; a prospective cohort analysis. BMC Pregnancy Childbirth 18: 1-10.
13. Kitui J, Lewis S, Davey G (2013) Factors influencing place of delivery for women in Kenya: an analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy Childbirth 13: 40.
14. Aliyu AA, Dahiru T (2017) Predictors of delayed Antenatal Care (ANC) visits in Nigeria: secondary analysis of 2013 Nigeria Demographic and Health Survey (NDHS). Pan Afr Med 26.
15. Okonofua F, Ntoimo L, Ogungbangbe J, Anjorin S, Imongan W, et al. (2018) Predictors of women’s utilization of primary health care for skilled pregnancy care in rural Nigeria. BMC Pregnancy Childbirth 18: 1-15.
16. Gupta S, Yamada G, Mpembeni R, Frumence G, Callaghan-Koru JA, et al. (2014) Factors associated with four or more antenatal care visits and its decline among pregnant women in Tanzania between 1999 and 2010. PloS One 9: e101893.
17. Mustafa MH, Mukhtar AM (2015) Factors associated with antenatal and delivery care in Sudan: analysis of the 2010 Sudan household survey. BMC Health Serv Res 15: 452.
18. Gebregziabher NK, Zeray AY, Abtew YT, Kinfe TD, Abrha DT (2019) Factors determining choice of place of delivery: analytical cross-sectional study of mothers in Akordet town, Eritrea. BMC Public Health 19: 924.
19. Asseffa NA, Bukola F, Ayodele A (2016) Determinants of use of health facility for childbirth in rural Hadiya zone, Southern Ethiopia. BMC Pregnancy Childbirth 16: 355.
20. Gitonga E, Muiruri F (2016) Determinants of health facility delivery among women in Tharaka Nithi county, Kenya. Pan Afr Med 25.
21. Mitsunaga TM, Larsen UM, Okonofua FE (2005) Risk factors for complications of induced abortions in Nigeria. J of Women's Health 14: 515-528.
22. Idowu AE, Edewor P, Amoo EO (2014) Working conditions and maternal health challenges in Lagos state, Nigeria. Res Human Soc Scienc 4: 136-147.
23. Olonade O, Olawande TI, Alabi OJ, Imhonopi D (2019) Maternal mortality and maternal health care in Nigeria: Implications for socio-economic development. Open Access Maced J Med Sci 7: 849.
24. Fisseha G, Berhane Y, Worku A, Terefe W (2017) Distance from health facility and mothers’ perception of quality related to skilled delivery service utilization in northern Ethiopia. Int J Womens Health 9: 749.
25. Gage AD, Carnes F, Blossom J, Aluvaala J, Amatya A, et al. (2019) In low-and middle-income countries, Is delivery in high-quality obstetric facilities geographically feasible? Health Aff 38: 1576-1584.
26. Boah M, Mahama AB, Ayamga EA (2018) They receive antenatal care in health facilities, yet do not deliver there: predictors of health facility delivery by women in rural Ghana. BMC Pregnancy Childbirth 18: 125.
27. Amouzou A, Ziqi M, Carvajal-Aguirre L, Quinley J (2017) Skilled attendant at birth and newborn survival in Sub-Saharan Africa. J Glob Health 7.
28. "Surulere Local Government Area in Nigeria". City Population. citypopulation.de. available from: https://www.citypopulation.de/php/nigeria-admin.php?adm2id=NGA025020. Retrieved 7 December 2019.
29. Nwankwo ON, Ani OE, Akpoke M, Ugwa EA (2019) Determinants of choice of place of delivery among women attending two referral hospitals in Kano North-West Nigeria. Niger Med J 60: 68.
30. Edvardsson K, Small R, Persson M, Lalos A, Mogren I (2014) Ultrasound is an invaluable third eye, but it can’t see everything: a qualitative study with obstetricians in Australia. BMC Pregnancy Childbirth 14: 363.
31. Haragan AF, Hulsey TC, Hawk AF, Newman RB, Chang EY (2015) Diagnostic accuracy of fundal height and handheld ultrasound-measured abdominal circumference to screen for fetal growth abnormalities. Am J Obstet Gynecol 212: 820-e1.
32. Lebit FD, Vladareanu R (2011) The role of 4D ultrasound in the assessment of fetal behaviour. Mædica 6: 120.
33. Zira JD (2017) Patient's satisfaction and perception of care during obstetrics ultrasound scan. PJR 27.
34. Eze CU, Okaro AO (2006) Survey of patient satisfaction with obstetric ultrasound service at University of Nigeria Teaching Hospital, Enugu, Nigeria. Nigerian J Health Biomed Sci 5: 93-97.
35. Ashimi AO, Amole TG (2015) Prevalence, reasons and predictors for home births among pregnant women attending antenatal care in Birnin Kudu, North-west Nigeria. Sex Reprod Healthc 6: 119-125.
36. Al-Mujtaba M, Cornelius LJ, Galadanci H, Erekaha S, Okundaye JN, et al. (2016) Evaluating religious influences on the utilization of maternal health services among Muslim and Christian women in North-Central Nigeria. Biomed Res Int.
37. Atinge S, Ogunnowo BE, Balogun M (2020) Factors associated with choice of non-facility delivery among women attending antenatal care in bali local government area of taraba state, North-Eastern Nigeria. Afr J Reprod Health 24: 143-151.
38. Sato C, Phongluxa K, Toyama N, Gregorio ER, Miyoshi C, et al. (2019) Factors influencing the choice of facility-based delivery in the ethnic minority villages of Lao PDR: a qualitative case study. Trop Med Health 47: 50.
39. Dickson KS, Adde KS, Amu H (2016) What influences where they give birth? Determinants of place of delivery among women in rural Ghana. Int J Reprod Biomed.
40. Enuameh YAK, Okawa S, Asante KP, Kikuchi K, Mahama E, et al. (2016) Factors influencing health facility delivery in predominantly rural communities across the three ecological zones in Ghana: a cross-sectional study. PLoS One 11: e0152235.
41. Yaya S, Bishwajit G, Uthman OA, Amouzou A (2018) Why some women fail to give birth at health facilities: A comparative study between Ethiopia and Nigeria. PloS One 13: e0196896.
42. Yegezu RT, Kitila SB (2015) Assessment of factors affecting choice of delivery place among pregnant women in Jimma Zone, South West Ethiopia: cross sectional study. J Womens Health Care 4: 1-4.
43. Adedokun ST, Uthman OA (2019) Women who have not utilized health Service for delivery in Nigeria: who are they and where do they live? BMC Pregnancy Childbirth 19: 93.
44. Ababulgu FA, Bekuma TT (2016) Delivery site preferences and associated factors among married women of child bearing age in Bench Maji Zone, Ethiopia. Ethiop J Health Sci 26: 45-54.
45. Yahya MB, Pumpaibool T (2019) Factors influencing the decision to choose a birth center by pregnant women in Gombe state Nigeria. J Health Res.
46. Envuladu EA, Agbo HA, Lassa S, Kigbu JH, Zoakah AI (2013) Factors determining the choice of a place of delivery among pregnant women in Russia village of Jos North, Nigeria: achieving the MDGs 4 and 5. Int J Med Biomed Res 2: 23-27.
47. Dahiru T, Oche OM (2015) Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J 31: 22.
48. Kifle MM, Kesete HF, Gaim HT, Angosom GS, Araya MB (2018) Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea. J Health Popul Nutr 37: 22.
49. Akter S, Rich JL, Davies K, Inder KJ (2020) Prevalence and factors associated with knowledge and access to delivery services at primary health care facilities amongst indigenous women in Khagrachhari district Bangladesh: A cross-sectional study. Midwifery 90: 102798.
50. Abimbola JM, Makanjuola AT, Ganiyu SA, Babatunde UMM, Adekunle DK, et al. (2016) Pattern of utilization of ante-natal and delivery services in a semi-urban community of North-Central Nigeria. Afr Health Sci 16: 962-971.
51. Kawungezi PC, AkiiBua D, Aleni C, Chitayi M, Niwaha A, et al. (2015) Attendance and utilization of antenatal care (ANC) services: multi-center study in upcountry areas of Uganda. Open J Prev Med 5: 132.
52. Weldearegay HG (2015) Factors affecting choice of place for childbirth among women in Ahferom Woreda, Tigray, 2013. J Pregnancy Child Health 2: 133.