Home childbirth among young mothers aged 15-24 years in Nigeria: A national population-based cross-sectional study

BMJ Open, Volume 9, No. 9, Year 2019

Interpretation

Objective To estimate the prevalence and identify factors associated with home childbirth (delivery) among young mothers aged 15-24 years in Nigeria. Design A secondary analysis of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (NDHS). Setting Nigeria. Participants A total of 7543 young mothers aged 15-24 years. Outcome measure Place of delivery. Results The prevalence of home delivery among young mothers aged 15-24 years was 69.5% (95% CI 67.1% to 71.8%) in Nigeria – 78.9% (95%CI 76.3% to 81.2%) in rural and 43.9% (95%CI 38.5% to 49.5%, p<0.001) in urban Nigeria. Using the Andersen's behavioural model, increased odds of home delivery were associated with the two environmental factors: rural residence (adjusted OR, AOR: 1.39, 95% CI 1.06 to 1.85) and regions of residence (North-East: AOR: 1.97, 95% CI 1.14 to 3.34; North-West: AOR: 2.94, 95% CI 1.80 to 4.83; and South-South: AOR: 3.81, 95% CI 2.38 to 6.06). Three of the enabling factors (lack of health insurance: AOR: 2.34, 95% CI 1.16 to 4.71; difficulty with distance to healthcare facilities: AOR: 1.48, 95% CI 1.15 to 1.88; and <4 times antenatal attendance: AOR: 3.80, 95% CI 3.00 to 4.85) similarly increased the odds of home delivery. Lastly, six predisposing factors - lack of maternal and husband's education, poor wealth index, Islamic religion, high parity and low frequency of listening to radio - were associated with increased odds of home delivery. Conclusions Young mothers aged 15-24 years had a higher prevalence of home delivery than the national average for all women of reproductive age in Nigeria. Priority attention is required for young mothers in poor households, rural areas, North-East, North-West and South-South regions. Faith-based interventions, a youth-oriented antenatal care package, education of girls and access to health insurance coverage are recommended to speed up the reduction of home delivery among young mothers in Nigeria. We analysed data sets from the Cross-Sectional Nigeria Demographic and Health Survey 2013 (NDHS 2013), a nationally representative survey conducted by the Nigerian Population Commission with technical assistance from ICF International.8 NDHS data are generally and freely available online (www.dhsprogram.com) on request from ICF International, USA. One of the key objectives of the 2013 survey was the provision of current and reliable data on maternal and child healthcare including fertility, mortality, nutritional status of mothers and children, and immunisation coverage in Nigeria.8 A three-stage cluster sampling method was used in the design of the 2013 NDHS and validated interviewer-administered questionnaires were used in gathering data from a total of 38 948 eligible women aged 15–49 years.8 A comprehensive description of sampling methods and the settings have previously been published for the 2013 NDHS.8 A total of 38 948 eligible women, aged 15–49 years, was interviewed in the 2013 NDHS. The present study was, however, restricted to a total of 7543 young mothers aged 15–24 years—young mothers with complete information on the place of their most recent live delivery within 5 years leading to the 2013 NDHS. This information was extracted from the children’s record file of the 2013 NDHS data. The designation of ‘young mothers’ as ‘aged 15–24 years’ was adapted from the definition of ‘youths’ by the UN,22 23 and previously published studies on maternal healthcare services utilisation.25–27 33 We used the checklist for the ‘Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)’ statement34 while reporting this study. The STROBE statement provides a checklist to guide the appropriate report of cohort, case-control and cross-sectional studies thereby enhancing the transparency of observational studies.34 The outcome of interest for this study was home childbirths among young mothers aged 15–24 years in Nigeria. ‘Homebirth’ was described as ‘home delivery’ or ‘non-use of healthcare facility for childbirth’ and its value was described by the variable ‘place of delivery’ in the 2013 NDHS data. This variable was dichotomised as ‘institutional delivery’ (delivery in government and private healthcare facilities, coded as ‘0’) and ‘home delivery’ (delivery in respondents’ home or ‘other homes’, coded as ‘1’).7 8 35 Health services utilisation is a complex phenomenon, hence the need for a proven theoretical framework for a better assessment and clearer understanding of the health service in question in the context of its associated factors. Andersen’s behavioural model36 readily comes handy in this respect given its relevance and practicality in demonstrating associations between risk factors and maternal healthcare services utilisation, and institutional delivery in the present instance. Several studies have used this model in assessing maternal healthcare services utilisation including antenatal attendance and health facility delivery.37–39 The original version of the model developed in the 1960s by Ronald M Andersen focused mainly on the family as the unit of analysis and proposes that utilisation of health services depends on three factors—predisposing (whether people are inclined to use services, eg, demographics and social structure), enabling (factors which facilitate or impede use of services, eg, family support, health insurance) and need (whether care is required/desired, both perceived and actual needs). This initial version of the model has undergone several modifications in which the unit of measurement has changed from family to individuals, and the determining factors now include ‘external environmental factors’ in the phase IV version of the model. We adapted this phase IV version as a theoretical framework in this study. We selected independent variables for the present study following an extensive literature review7 10 25 26 40 with consideration for the available information in the 2013 NDHS.8 The variables were classified into four categories using Andersen’s model (figure 1) as follows: Theoretical framework for studying factors associated with home child delivery in Nigeria (adapted from Andersen36) We summarised the distribution of study participants (number and %) and estimated the prevalence of home delivery (in %). To test the association between the prevalence of home delivery and each independent variable, χ2 tests were performed. We carried out simple logistic regression analyses and reported the 95% CI alongside p values to assess the unadjusted association between home delivery and the various independent variables included in this study. To assess the adjusted association between the outcome and the independent variables, we carried out multivariable binary logistic regression analyses. In conducting multivariable logistic regression analyses, we built four parsimonious models hierarchically using the backward elimination method. First, we examined all ‘external environmental factors’ in Model I and retained those that were significant at p<0.05 (5% significance level). ‘Predisposing factors’ were then added to Model I with those ‘external environmental factors’ retained to establish Model II and significant factors with a p<0.05 were similarly retained for the next model. Model III comprised factors retained in Model II together with the ‘enabling factors’. Model IV adjusted for factors retained in Model III in the presence of the ‘need factor’. We reported the adjusted OR (AOR), their corresponding 95% CIs and p values for each of Models I–IV. To minimise possible statistical errors, we double-checked our analysis and tested the final parsimonious model against factors previously reported to be associated with home delivery. All our analyses were conducted using the Statistical Package for Social Sciences (SPSS) V.21. In line with practice in previous studies,35 37 43 44 we adjusted for the sample weight and the multistage cluster design of the NDHS data using the complex sample function in SPSS.45 While analysing data with the cluster sampling design and stratifications, complex sample statistics account for the complex survey sample design and the unequal selection probability thus enhancing the statistical reliability of estimates.45 To do this, we prepared a complex sample plan which specifies what SPSS needs to consider—sampling weights, strata and cluster—during data analysis. Missing values were excluded in all analyses. In this paper, where appropriate, ‘home delivery’, ‘home births’, ‘home childbirth’ and ‘non-use/utilisation of healthcare facility for childbirth’ were used synonymously. Similarly, ‘health facility delivery’, ‘facility-based delivery’ and ‘institutional delivery’ were used interchangeably as appropriate. Where applicable, ‘young mothers’ was used generally for mothers aged 15–24 years while ‘all women of reproductive age’ (15–49 years) represents the national average. The present study was based on a secondary analysis of existing data, hence, there was no involvement of patients in the study. However, there was public involvement (relevant stakeholders including governmental, non-governmental and international organisations) in the design and execution of the survey (2013 NDHS) that produced the data on which the present study was based. Details of these have been published.8

AI Digest

Study Justification:

The study aimed to estimate the prevalence and identify factors associated with home childbirth among young mothers aged 15-24 years in Nigeria. This is an important area of research because home childbirth can pose risks to both the mother and the baby, and understanding the factors that contribute to home childbirth can help inform interventions and policies to improve maternal and child health outcomes.

Study Highlights:

– The prevalence of home delivery among young mothers aged 15-24 years in Nigeria was found to be 69.5%.
– Rural residence and specific regions of residence (North-East, North-West, and South-South) were associated with increased odds of home delivery.
– Factors such as lack of health insurance, difficulty with distance to healthcare facilities, and low antenatal attendance also increased the odds of home delivery.
– Predisposing factors such as lack of education, poor wealth index, Islamic religion, high parity, and low frequency of listening to the radio were associated with increased odds of home delivery.

Study Recommendations:

– Priority attention should be given to young mothers in poor households, rural areas, and specific regions (North-East, North-West, and South-South) to reduce the prevalence of home delivery.
– Faith-based interventions, a youth-oriented antenatal care package, education of girls, and access to health insurance coverage are recommended to speed up the reduction of home delivery among young mothers in Nigeria.

Key Role Players:

– Governmental organizations
– Non-governmental organizations
– International organizations
– Healthcare providers
– Community leaders
– Educators
– Faith-based organizations

Cost Items for Planning Recommendations:

– Development and implementation of faith-based interventions
– Design and implementation of a youth-oriented antenatal care package
– Education programs for girls
– Establishment of health insurance coverage for young mothers
– Training and capacity building for healthcare providers
– Community outreach and awareness campaigns
– Monitoring and evaluation of interventions
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on the specific details and scope of each recommendation.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it is based on a secondary analysis of cross-sectional data from a nationally representative survey. The study provides prevalence estimates and identifies factors associated with home childbirth among young mothers in Nigeria. The use of Andersen’s behavioral model as a theoretical framework strengthens the study. However, the evidence could be improved by providing more details on the sampling method, data collection process, and statistical analysis techniques used.

Abstract

We analysed data sets from the Cross-Sectional Nigeria Demographic and Health Survey 2013 (NDHS 2013), a nationally representative survey conducted by the Nigerian Population Commission with technical assistance from ICF International.8 NDHS data are generally and freely available online (www.dhsprogram.com) on request from ICF International, USA. One of the key objectives of the 2013 survey was the provision of current and reliable data on maternal and child healthcare including fertility, mortality, nutritional status of mothers and children, and immunisation coverage in Nigeria.8 A three-stage cluster sampling method was used in the design of the 2013 NDHS and validated interviewer-administered questionnaires were used in gathering data from a total of 38 948 eligible women aged 15–49 years.8 A comprehensive description of sampling methods and the settings have previously been published for the 2013 NDHS.8 A total of 38 948 eligible women, aged 15–49 years, was interviewed in the 2013 NDHS. The present study was, however, restricted to a total of 7543 young mothers aged 15–24 years—young mothers with complete information on the place of their most recent live delivery within 5 years leading to the 2013 NDHS. This information was extracted from the children’s record file of the 2013 NDHS data. The designation of ‘young mothers’ as ‘aged 15–24 years’ was adapted from the definition of ‘youths’ by the UN,22 23 and previously published studies on maternal healthcare services utilisation.25–27 33 We used the checklist for the ‘Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)’ statement34 while reporting this study. The STROBE statement provides a checklist to guide the appropriate report of cohort, case-control and cross-sectional studies thereby enhancing the transparency of observational studies.34 The outcome of interest for this study was home childbirths among young mothers aged 15–24 years in Nigeria. ‘Homebirth’ was described as ‘home delivery’ or ‘non-use of healthcare facility for childbirth’ and its value was described by the variable ‘place of delivery’ in the 2013 NDHS data. This variable was dichotomised as ‘institutional delivery’ (delivery in government and private healthcare facilities, coded as ‘0’) and ‘home delivery’ (delivery in respondents’ home or ‘other homes’, coded as ‘1’).7 8 35 Health services utilisation is a complex phenomenon, hence the need for a proven theoretical framework for a better assessment and clearer understanding of the health service in question in the context of its associated factors. Andersen’s behavioural model36 readily comes handy in this respect given its relevance and practicality in demonstrating associations between risk factors and maternal healthcare services utilisation, and institutional delivery in the present instance. Several studies have used this model in assessing maternal healthcare services utilisation including antenatal attendance and health facility delivery.37–39 The original version of the model developed in the 1960s by Ronald M Andersen focused mainly on the family as the unit of analysis and proposes that utilisation of health services depends on three factors—predisposing (whether people are inclined to use services, eg, demographics and social structure), enabling (factors which facilitate or impede use of services, eg, family support, health insurance) and need (whether care is required/desired, both perceived and actual needs). This initial version of the model has undergone several modifications in which the unit of measurement has changed from family to individuals, and the determining factors now include ‘external environmental factors’ in the phase IV version of the model. We adapted this phase IV version as a theoretical framework in this study. We selected independent variables for the present study following an extensive literature review7 10 25 26 40 with consideration for the available information in the 2013 NDHS.8 The variables were classified into four categories using Andersen’s model (figure 1) as follows: Theoretical framework for studying factors associated with home child delivery in Nigeria (adapted from Andersen36) We summarised the distribution of study participants (number and %) and estimated the prevalence of home delivery (in %). To test the association between the prevalence of home delivery and each independent variable, χ2 tests were performed. We carried out simple logistic regression analyses and reported the 95% CI alongside p values to assess the unadjusted association between home delivery and the various independent variables included in this study. To assess the adjusted association between the outcome and the independent variables, we carried out multivariable binary logistic regression analyses. In conducting multivariable logistic regression analyses, we built four parsimonious models hierarchically using the backward elimination method. First, we examined all ‘external environmental factors’ in Model I and retained those that were significant at p<0.05 (5% significance level). ‘Predisposing factors’ were then added to Model I with those ‘external environmental factors’ retained to establish Model II and significant factors with a p<0.05 were similarly retained for the next model. Model III comprised factors retained in Model II together with the ‘enabling factors’. Model IV adjusted for factors retained in Model III in the presence of the ‘need factor’. We reported the adjusted OR (AOR), their corresponding 95% CIs and p values for each of Models I–IV. To minimise possible statistical errors, we double-checked our analysis and tested the final parsimonious model against factors previously reported to be associated with home delivery. All our analyses were conducted using the Statistical Package for Social Sciences (SPSS) V.21. In line with practice in previous studies,35 37 43 44 we adjusted for the sample weight and the multistage cluster design of the NDHS data using the complex sample function in SPSS.45 While analysing data with the cluster sampling design and stratifications, complex sample statistics account for the complex survey sample design and the unequal selection probability thus enhancing the statistical reliability of estimates.45 To do this, we prepared a complex sample plan which specifies what SPSS needs to consider—sampling weights, strata and cluster—during data analysis. Missing values were excluded in all analyses. In this paper, where appropriate, ‘home delivery’, ‘home births’, ‘home childbirth’ and ‘non-use/utilisation of healthcare facility for childbirth’ were used synonymously. Similarly, ‘health facility delivery’, ‘facility-based delivery’ and ‘institutional delivery’ were used interchangeably as appropriate. Where applicable, ‘young mothers’ was used generally for mothers aged 15–24 years while ‘all women of reproductive age’ (15–49 years) represents the national average. The present study was based on a secondary analysis of existing data, hence, there was no involvement of patients in the study. However, there was public involvement (relevant stakeholders including governmental, non-governmental and international organisations) in the design and execution of the survey (2013 NDHS) that produced the data on which the present study was based. Details of these have been published.8

Materials

Innovations

The study titled “Home childbirth among young mothers aged 15-24 years in Nigeria: A national population-based cross-sectional study” provides valuable insights into the prevalence and factors associated with home childbirth in Nigeria. Based on the findings of this study, several recommendations can be developed into innovations to improve access to maternal health:

1. Faith-based interventions: Implement interventions that involve religious leaders and organizations to promote the importance of institutional delivery and provide education on the benefits of accessing healthcare facilities for childbirth. This can be done through awareness campaigns, community outreach programs, and collaboration with religious institutions.

2. Youth-oriented antenatal care package: Develop and implement antenatal care programs specifically tailored to the needs of young mothers aged 15-24 years. These programs should address their unique challenges and provide comprehensive support, education, and counseling on maternal health. This can include age-appropriate information, peer support groups, and youth-friendly healthcare services.

3. Education of girls: Focus on improving access to education for girls, as higher levels of education have been associated with a decreased likelihood of home delivery. By empowering young girls through education, they are more likely to make informed decisions about their reproductive health and seek appropriate healthcare services. This can be achieved through initiatives that promote girls’ education, scholarships, and community awareness campaigns on the importance of girls’ education.

4. Access to health insurance coverage: Increase access to health insurance coverage for young mothers, as the lack of health insurance was found to increase the odds of home delivery. This can be achieved through government initiatives, partnerships with private insurers, or community-based health insurance programs. Efforts should be made to ensure that health insurance coverage is affordable and accessible to young mothers.

By implementing these recommendations, it is expected that the prevalence of home delivery among young mothers in Nigeria will decrease, leading to improved access to maternal health services and better health outcomes for both mothers and infants.

AI Innovations Description

Based on the findings of the study titled “Home childbirth among young mothers aged 15-24 years in Nigeria: A national population-based cross-sectional study,” the following recommendations can be developed into an innovation to improve access to maternal health:

1. Faith-based interventions: Implement interventions that involve religious leaders and organizations to promote the importance of institutional delivery and provide education on the benefits of accessing healthcare facilities for childbirth.

2. Youth-oriented antenatal care package: Develop and implement antenatal care programs specifically tailored to the needs of young mothers aged 15-24 years. These programs should address their unique challenges and provide comprehensive support, education, and counseling on maternal health.

3. Education of girls: Focus on improving access to education for girls, as higher levels of education have been associated with a decreased likelihood of home delivery. By empowering young girls through education, they are more likely to make informed decisions about their reproductive health and seek appropriate healthcare services.

4. Access to health insurance coverage: Increase access to health insurance coverage for young mothers, as the lack of health insurance was found to increase the odds of home delivery. This can be achieved through government initiatives, partnerships with private insurers, or community-based health insurance programs.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Faith-based interventions: Implement a pilot program in selected regions of Nigeria where religious leaders and organizations are engaged to promote the importance of institutional delivery. Track the number of young mothers who access healthcare facilities for childbirth before and after the intervention. Compare the data to regions where the intervention was not implemented to measure the impact.

2. Youth-oriented antenatal care package: Develop and implement a specialized antenatal care program for young mothers aged 15-24 years in selected healthcare facilities. Monitor the number of young mothers attending antenatal care, the number of institutional deliveries, and maternal health outcomes. Compare the data to facilities where the program was not implemented to assess the effectiveness.

3. Education of girls: Collaborate with educational institutions and organizations to improve access to education for girls in selected regions. Monitor the enrollment rates of girls in schools and track their reproductive health decisions, including the choice of healthcare facilities for childbirth. Compare the data to regions where educational interventions were not implemented to evaluate the impact.

4. Access to health insurance coverage: Implement a health insurance program specifically targeting young mothers aged 15-24 years in selected regions. Monitor the enrollment rates and utilization of healthcare services among insured young mothers. Compare the data to regions without health insurance coverage to assess the effectiveness of the program.

Collect data on the outcomes of each recommendation, including the number of institutional deliveries, maternal health outcomes, and any changes in the prevalence of home delivery among young mothers aged 15-24 years. Analyze the data using statistical methods to determine the impact of each recommendation on improving access to maternal health.

By using this methodology, policymakers and stakeholders can evaluate the effectiveness of the recommendations and make informed decisions on scaling up successful interventions to improve access to maternal health services in Nigeria.

Author

Dima Health

Statistics:

Citations: 4

Identifiers:

DOI: 10.1136/bmjopen-2018-025494

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Nigeria

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female