• Users Online: 146
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 19-24

Trends in the use of skilled birth attendants among women of reproductive age in a resource-limited setting


1 Department of Public Health, Walden University, Minneapolis, MN, USA
2 Department of Family Medicine, Lagos State Health Service Commission, Lagos, Nigeria
3 Department of Public health, University of Central Nicaragua, Managua, Nicaragua
4 Department of Logistics and Supply Chain Management, University of Science and Technology, Selangor, Malaysia
5 Surveillance Department, Nigeria Center for Disease Control, Jabi Abuja, Nigeria
6 Department of Strategic Supply Chain Management, University of Roehampton, London, UK
7 Department of Public Health, Texila American University,  
8 Department of Procurement and Supply Chain Management, Akesis, Abuja, Nigeria
9 Research and Development Department, Fescosof Data Soultions, Ogun State, Nigeria

Date of Submission20-Oct-2021
Date of Acceptance02-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Uduak Bassey
Department of Public Health, Walden University, Minneapolis, MN.
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_78_21

Rights and Permissions
  Abstract 

Background: Although there has been growing awareness on the need for professional assistance at delivery, and this has improved health-seeking behavior and the use of antenatal care (ANC) of pregnant women, presenting for ANC does not directly imply that a woman would use a skilled birth attendant (SBA) at delivery. This study analyzed the trend in the use of SBAs at delivery among Nigerian reproductive women from 2007 to 2017. Materials and Methods: The study used the United Nations Children’s Fund, Multiple Indicator Cluster Surveys data for the years 2007 (n = 1021), 2011 (n = 2927), and 2016/2017 (n = 4155). Multivariate logistic regression was used to determine the relationship between the use of SBAs and demographic characteristics of women aged 15–49 years in Nigeria. Results: There was a significant decline in the utilization of SBAs at delivery from 82.7% in 2007 to 71.8% in 2016/2017 (P < 0.001). There was a decline in the proportion of doctors and nurses/midwives as birth attendants from 28.3% and 54.4% in 2007 to 22.8% and 49.0% in 2016/2017, respectively (P < 0.001), whereas the use of traditional birth attendants increased from 5.2% to 8.0% during the periods (P = 0.003). Urban residence [adjusted odds ratio (AOR)=1.32, 95% confidence interval (CI)=1.18–1.47, P < 0.01], higher maternal age (AOR=1.49, 95% CI=1.30–1.70; P < 0.01), and education attainment (AOR=3.78, 95% CI=3.39–4.22; P < 0.001) were associated with higher odds of the utilization of SBAs. Conclusion: There is a need for intervention programs for women in rural areas and women with a low level of education and lower maternal age. This will further reduce the maternal mortality ratios of the country.

Keywords: Antenatal care, birth attendants, maternal health, Nigeria, reproductive age


How to cite this article:
Bassey U, Oyewande AA, Chukwunonye AI, Ajani OF, Sunday ST, Omole TM, Igbinovia FI, Chiroma BB, Gwa ZT, Abiodun OP, Sanni FO. Trends in the use of skilled birth attendants among women of reproductive age in a resource-limited setting. MGM J Med Sci 2022;9:19-24

How to cite this URL:
Bassey U, Oyewande AA, Chukwunonye AI, Ajani OF, Sunday ST, Omole TM, Igbinovia FI, Chiroma BB, Gwa ZT, Abiodun OP, Sanni FO. Trends in the use of skilled birth attendants among women of reproductive age in a resource-limited setting. MGM J Med Sci [serial online] 2022 [cited 2022 May 18];9:19-24. Available from: http://www.mgmjms.com/text.asp?2022/9/1/19/340593




  Introduction Top


One of the major determinants of maternal and child health outcomes is a skilled birth attendant (SBA) at delivery.[1],[2],[3] Over the years, there has been growing awareness of the need for professional assistance at delivery, which has improved the health-seeking behavior of pregnant women and uptake of antenatal care (ANC) services.[3] Nevertheless, presenting for ANC does not directly imply that a woman would deliver her child in a health facility. Pregnancy is seen in many African cultures as the natural physiological phase women undertake and not as a severe disorder that needs specialized treatment except in an emergency.[4],[5] These perceptions encourage the practice of home deliveries where women prefer the services of unskilled or semiskilled traditional birth attendants (TBAs), which have been implicated in a high rate of pregnancy-related morbidity and mortality in Sub-Saharan Africa.[2]

In Nigeria, about 65% of births still occur at home under the supervision of TBAs.[1],[6] This high rate of home deliveries is similar to findings from other low resource settings in which socio-cultural norms promote patronage of unofficial health professionals.[2] Factors influencing low uptake of hospital deliveries include long distance to health facilities, security concerns if a woman goes into labor in the middle of the night, high obstetric charges, non-attendance at ANC, poor attitude from health workers, socio-cultural norms, including the need for spousal approval and commitment, and previous successful home delivery.[2],[3],[4],[5]

In rural areas where the health staff is directly known to the facilities users, women may be unwilling to seek assistance from the official health sectors because of security issues concerning human immunodeficiency virus (HIV) and prevention of mother-to-child transmission (PMTCT).[7] This often leads to reliance on TBAs, mostly older women perceived to be more sympathetic and patient with their clients than nurses and who may not require the women to carry out HIV testing before being attended.[4],[5],[6],[7] However, there are many challenges with home deliveries, including the increased risk for vertical transmission of HIV due to inadequate knowledge of some birth attendants to guide clients or integrate PMTCT program in their regular obstetric care,[6] thereby affecting the expected outcome of PMTCT in low-resource settings. This study aims to analyze the trend in the use of SBAs at delivery among women of reproductive age in Nigeria from 2007 to 2017.[8]


  Materials and methods Top


The research is based on the United Nations Children’s Fund (UNICEF), Multiple Indicator Cluster Surveys (MICS) secondary data obtained from the citizens of Nigeria in 2007, 2011, and 2016/2017.[9] The data were recovered from the electronic data management system of UNICEF and downloaded. Before utilizing the results, UNICEF approval was obtained, typically involving online registration and acceptance via e-mail. Information from women of reproductive age who have had a live birth within 2 years was extracted and analyzed. Entries with missing data were excluded from the analysis.

Population

The research involved women between 15 and 49 years of age who were pregnant 2 years before data collection. This is the perfect research group for determining the use of skilled birth attendance among women,[10] and the possibility of using SBAs among perinatal women will become more apparent.

Sampling and sampling procedures

Multiple stages were used to select respondents for the MICS survey. First, a random sample of areas marked for the study was chosen according to the size of each designated area. The MICS sample of respondents was drawn up in several steps. First, a random sampling of the sites was done according to the size of each listed area. A random sample of 20–30 households was then selected in each enumerated region. All women aged 15–49 years were eventually interviewed in every home. For each year, the sample consisted of 27,093, 33,699, and 36,176 women.

Data analysis

The abstracted data were transferred to the analysis software IBM-SPSS version 25, ensuring that all data components were accessible and the variables were grouped into categories. Data with missing or incomplete information were removed. Descriptive analysis and multivariate regression were performed to test the association between dependent and independent variables. A binary logistics regression analysis was used. The significance level was set at 0.05.

Ethical procedures

Permission to use rounds 3, 4, and 5 of the UNICEF MICS data was requested and received from the UNICEF MICS team. Permission to use the data was issued after completing an online application process defining the purpose of using the data.


  Results Top


The study used data from 8103 eligible women across the country, comprising 1021 from 2007, 2927 from 2011, and 4155 from 2016/2017 national surveys. [Table 1] shows the trend in using both skilled and unskilled birth attendants at delivery among the women. The use of doctors at delivery declined from 28.3% in 2007 to 22.8% in 2016/17 (P < 0.001). A similar trend was observed in the use of a nurse/midwife from 54.4% in 2007 to 49.0% in 2016/17. In contrast, the proportion of TBAs at delivery increased from 5.2% in 2007 to 8.0% in 2016/2017 (P = 0.003). Also, community health workers’ birth attendance increased from 0.8% in 2007 to 1.5% and 1.3% in 2011 and 2016/2017, respectively. As shown in [Figure 1], the use of birth attendants significantly reduced from 82.7% in 2007 to 71.8% in 2016/17.
Table 1: Birth attendants at delivery of Nigerian women of reproductive age between 2007 and 2017

Click here to view
Figure 1: Trend in the use of skilled birth attendants at delivery by reproductive-aged women over three periods

Click here to view


Factors associated with the use of SBAs among Nigerian women of reproductive age

Over the three periods, the use of birth SBAs was significantly higher among women aged 35 or more years (78.0%) than those younger than 35 years (P = 0.012). The use of SBAs was also higher among women who attained secondary education or more (82.9%) and those who lived in urban areas (78.8%) (P < 0.001). A slightly higher proportion (75.8%) of women who were married at the time of the surveys used SBAs than those who were not married (74.1%) (P = 0.698), as shown in [Table 2].
Table 2: Crosstabulation of women’s use of skilled birth attendant at delivery over three periods

Click here to view


The respondents’ area of residence and educational attainment are the explanatory variables (independent variables), whereas skilled birth attendants are the dependent variable. Women who lived in urban areas were [(adjusted odds ratio (AOR)=2.63, 95% confidence interval (CI)=1.83–3.78; P < 0.001), (AOR = 0.44, 95% CI = 0.36–0.55; P < 0.001), and (AOR = 1.83, 95% CI = 1.57–2.13, P < 0.001)] more likely to use SBAs in 2007, 2011, and 2016/2017, respectively, than those who lived in rural areas. A similar trend was observed among educated women when compared with uneducated ones. Overall, women who live in urban areas were (AOR = 1.32, 95% CI = 1.18–1.47, P < 0.01) more likely to use SBAs than their counterparts in rural areas. Similarly, women aged 35 years and above and women who had secondary or more education were [(AOR = 1.49, 95% CI = 1.30–1.70; P < 0.01) and (AOR = 3.78, 95% CI = 3.39–4.22; P < 0.001)] more likely to use SBAs at delivery than those younger than 35 years and did not have secondary education [Table 3].
Table 3: Logistic regression showing factors associated with the use of skilled birth attendant at delivery for over the three periods

Click here to view



  Discussion Top


This study discovered a consistent decline in the use of SBAs and an increase in the use of unskilled birth attendants at delivery among Nigerian women of reproductive age between 2007 and 2017. The drop in SBAs at delivery from 82.7% in 2007 to 71.8% in 2016/2017, despite the increased number of women attending ANC within these periods, is a serious issue that requires serious attention. This study showed an increase in the proportion of TBAs at delivery from 5.2% in 2007 to 8.0% in 2016/2017. However, delivery by doctors and nurses/midwives dropped from 28.3% and 54.4% to 22.8% and 49%. This might be why the maternal mortality ratio remains very high in Nigeria and other Sub-Saharan African countries. Although the maternal mortality ratio reduced worldwide by 38% from 2000 to 2017, the highest (86%) maternal deaths were recorded in Sub-Saharan Africa and Southern Asia in 2017,[11] with Nigeria ranked fourth in Africa behind South Sudan, Chad, and Sierra Leone, having recorded 917 (500–999) per 100,000 live births.[9]

This evidence of low usage of SBAs at delivery is similar to findings from a trend study[8] using data from the Nigerian Demographic and Health Survey, in which there was a non-significant marginal change in the use of SBAs from 1990 (32.4%) to 2013 (38.5%) in Nigeria. Another study conducted to determine the utilization of SBAs over time in Nigeria and Malawi reported a similar declining trend that Nigerian women were 23% less likely to utilize SBAs at delivery in 2013 compared with 2003.[12] A similar study conducted among Nigerian women within 2 years postpartum found that only 49% used SBAs during their last childbirth.[13] However, a recent study in Southern Nigeria reported higher utilization of SBAs (88.2%).[14] Another study conducted among pregnant women in Ogun State, South-West, Nigeria also found higher (83.8%) utilization of SBAs. In contrast, in Sokoto State, Northern Nigeria, SBAs at delivery among women in urban areas were far higher (70.0%) than those in rural areas (4.3%).[15] Also, among adolescent married women aged 15–19 years in Nigeria between 2016 and 2017, only 27% used SBAs at delivery. This implies that the declining utilization rate of SBAs in Nigeria over the three periods is largely influenced by the region, areas of residence, and age as found in several previous studies enumerated in this section.

Factors associated with use of SBAs at delivery among Nigeria women include being 35 years or more (AOR = 1.49, 95% CI = 1.30–1.70; P < 0.01), residing in urban areas (AOR = 1.32, 95% CI = 1.18–1.47, P < 0.01), and attaining at least secondary education (AOR = 3.78, 95% CI = 3.39–4.22; P < 0.001). This implies that older women were 1.49 times more likely to use SBAs than younger women. This might be due to better child delivery experience among older women than the younger ones. This finding agrees with Ogboghodo et al.,[14] who reported that the utilization of SBAs was higher among older women than the younger ones.

Also, women who reside in urban areas were more likely to use SBAs than their rural counterparts due to higher availability and better health facilities in the cities than in villages. It might also be attributed to regular and better awareness interventions in urban areas. Women in urban areas were more exposed to maternal health-related information through various media such as television, radio, and social media platforms. Other factors that could have contributed to the poor utilization of SBAs in rural areas include poverty, poor healthcare system, and services, inadequate information as well as religious and cultural belief, as documented earlier by previous scholars.[11],[16],[17],[18],[19],[20]

The highest predictor of the use of skilled birth at delivery in this study is education. Educated women were approximately four times more likely to use SBAs at delivery than their uneducated counterparts. This is not unexpected as educated women are more exposed to maternally related information than the uneducated due to their ability to read, understand, and write. This result agrees with what was obtained in a study to assess the trends and drivers of the utilization of unskilled birth attendants during democratic governance in Nigeria from 1999 to 2018.[21] The study found that higher maternal age 35–49 years and higher education attainment were associated with higher odds of utilizing SBAs, whereas rural residence and lower maternal age (15–24 years) were associated with lower odds of using SBAs at delivery.


  Conclusion Top


This study found a significant decline in the utilization of SBAs among Nigerian women of reproductive age from 2007 to 2016/2017. Factors such as age, area of residence, and education were identified to significantly influence the use of SBAs among women. A comparative analysis of the findings of this study with some previous studies in Nigeria shows that although some regions recently recorded high utilization of SBAs at delivery, some recorded low use of them. Further study is needed to determine the trend of the utilization of SBAs among women from different geopolitical zones in the country. This will further reveal any regional disparity and enable policymakers to design appropriate interventions and channel them toward the most affected regions. The findings of this study clearly showed that there is a need for more intervention programs such as sensitization and free maternal care for women in rural areas and women with a low level of education and lower maternal age. This will further reduce the maternal mortality ratios of the country.

Ethical consideration

The data were collected from the office of the United Nations Children’s Fund (UNICEF), Multiple Indicator Cluster Surveys (MICS), New York, USA. The permission to use rounds 3, 4, and 5 of the UNICEF, MICS was received from their team after completing an online application process defining the purpose of using the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abiodun O, John S, Oluwatosin O-A, Franklin A, Agboola T, Taiwo O The effect of training on traditional birth attendants’ PMTCT related knowledge and care practices in Nigeria. J AIDS Clin Res 2015;6:498. https://doi.org/10.4172/2155–6113.1000498  Back to cited text no. 1
    
2.
Chea SK, Mwangi TW, Ndirangu KK, Abdullahi OA, Munywoki PK, Abubakar A, et al. Prevalence and correlates of home delivery amongst HIV-infected women attending care at a rural public health facility in Coastal Kenya. PLoS One 2018;13:e0194028.  Back to cited text no. 2
    
3.
Dahiru T, Oche OM Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J 2015;21:321.  Back to cited text no. 3
    
4.
Ehiri JE, Iwelunmor J, Iheanacho T, Blackstone S, Obiefune MC, Ogidi AG, et al. Using a cultural framework to understand factors influencing HIV testing in Nigeria. Int Q Community Health Educ 2016;37:33-42.  Back to cited text no. 4
    
5.
Sinai I, Anyanti J, Khan M, Daroda R, Oguntunde O Demand for women’s health services in Northern Nigeria: A review of the literature. Afr J Reprod Health 2017;21:96-108.  Back to cited text no. 5
    
6.
Chizoba AF, Pharr JR, Oodo G, Ezeobi E, Ilozumb J, Egharevba J, et al. Increasing HIV testing among pregnant women in Nigeria: Evaluating the traditional birth attendant and primary health center integration (TAP-In) model. AIDS Care 2017;29:1094-8.  Back to cited text no. 6
    
7.
Ehiri JE, Alaofè HS, Yesufu V, Balogun M, Iwelunmor J, Kram NA, et al. AIDS-related stigmatisation in the healthcare setting: A study of primary healthcare centres that provide services for prevention of mother-to-child transmission of HIV in Lagos, Nigeria. BMJ Open 2019;9:e026322.  Back to cited text no. 7
    
8.
Fagbamigbe AF, Hurricane-Ike EO, Yusuf OB, Idemudia ES Trends and drivers of skilled birth attendant use in Nigeria (1990-2013): Policy implications for child and maternal health. Int J Womens Health 2017;9:843-53.  Back to cited text no. 8
    
9.
United Nations Children Fund. UNICEF Data: Monitoring the situation of children and women. Maternal Mortality. New York: UNICEF; 2019. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/ [last accessed on October 15, 2021].  Back to cited text no. 9
    
10.
Olakunde BO, Adeyinka DA, Olawepo JO, Pharr JR, Ozigbu CE, Wakdok S, et al. Towards the elimination of mother-to-child transmission of HIV in Nigeria: A health system perspective of the achievements and challenges. Int Health 2019;11:240-9.  Back to cited text no. 10
    
11.
World Health Organization. Maternal Mortality. Factsheets. Geneva: WHO; 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality [last accessed on October 15, 2021].  Back to cited text no. 11
    
12.
Atuoye KN, Amoyaw JA, Kuuire VZ, Kangmennaang J, Boamah SA, Vercillo S, et al. Utilisation of skilled birth attendants over time in Nigeria and Malawi. Glob Public Health 2017;12:728-43.  Back to cited text no. 12
    
13.
Okigbo CC, Eke AC Skilled birth attendance in Nigeria: A function of frequency and content of antenatal care. Afr J Reprod Health 2015;19:25-33.  Back to cited text no. 13
    
14.
Ogboghodo EO, Adam VY, Omuemu VO, Okojie OH Knowledge, attitude, and utilization of skilled birth attendants in a rural community in Southern Nigeria: A mixed-method survey. Int J Med Sci Public Health 2019;7:61-9.  Back to cited text no. 14
    
15.
Shehu CE, Ibrahim MTO, Oche MO, Nwobodo EI Determinants of place of delivery: A comparison between an urban and a rural community in Nigeria. J Public Health Epidemiol 2016;8:91-101. https://doi.org/10.5897/jphe2016.0817  Back to cited text no. 15
    
16.
Meh C, Thind A, Ryan B, Terry A Levels and determinants of maternal mortality in northern and southern Nigeria. BMC Pregnancy Childbirth 2019;19:417.  Back to cited text no. 16
    
17.
Mojekwu JN, Ibekwe U Maternal mortality in Nigeria: Examination of intervention methods. Int J Humanit Soc Sci 2012;2:135-49.  Back to cited text no. 17
    
18.
Olowokere AE, Oyedele AT, Komolafe AO, Olajubu AO Birth preparedness, utilization of skilled birth attendants and delivery outcomes among pregnant women in Ogun state, Nigeria. Eur J Midwifery 2020;4:22.  Back to cited text no. 18
    
19.
Oyeneyin LO, Akintan AL, Aderoba AK, Owa OO Maternal mortality ratio in a tertiary hospital offering free maternity services in South-Western Nigeria—A five-year review. Tro J Obstet Gynaecol 2017;34:112-5.  Back to cited text no. 19
    
20.
Usman NO, Abdullahi HM, Nmadu AG, Omole VN, Ango UT Estimation of maternal mortality by sisterhood method in two rural communities in Kaduna State, Nigeria. J Med Trop 2019;21:62-6.  Back to cited text no. 20
    
21.
Ogbo FA, Trinh FF, Ahmed KY, Senanayake P, Rwabilimbo AG, Uwaibi NE, et al. Prevalence, trends, and drivers of the utilization of unskilled birth attendants during democratic governance in Nigeria from 1999 to 2018. Int J Environ Res Public Health 2020;17:372. doi:10.3390/ijerph17010372  Back to cited text no. 21
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed340    
    Printed28    
    Emailed0    
    PDF Downloaded53    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]