Return for prenatal care and childbirth services among Nigerian women using primary health care facilities

Abstract Aim The study assessed the return for prenatal care and childbirth services among Nigerian women using primary health care facilities. Design A descriptive cross‐sectional approach was employed for the study. Methods A total of 730 participants randomly recruited systematically from 21 purposively selected primary health care facilities in Ibadan, Nigeria were studied. A questionnaire and a checklist were used for data collection. The collection of data spanned three months (April to June, 2014). The data were analysed descriptively and inferentially while the results were presented in frequency tables. Results The women's mean age was 28 ± 5.3 years. Out of the 730 women studied, 92.6% received prenatal care. The mean difference between the number of prenatal care registration and the number of childbirths was 76.5. Poor environmental hygiene of facilities, statistically significant cost of services and non‐availability of 24‐hr service were implicated for dissatisfaction with care received by the women and consequent poor return rate for childbirth.

The quality of places of prenatal care and childbirth services is a product of whether the women are able to access skilled birth attendants or not in such places (Lee, Holden, & Ayers, 2016;Seljeskog, Sundby, & Chimango, 2007). The choice of place of accessing prenatal and childbirth care seems to be critical to neonatal and maternal pregnancy outcomes (Seljeskog et al., 2007). This is so because fewer pregnant women have been observed not to return to the place of their initial antenatal registration for childbirth. This is why the safety of choice of home births and the women's right to make such a choice, when hospital birth is an available safer option still remains controversial issue in developing countries. Although the undesirable outcomes of home delivery such as high maternal and perinatal mortalities or morbidities in developing countries like Nigeria are well-documented, the success of planned home birth undertaken by unskilled birth attendants have not been reported in the literature (Janssen et al., 2009). Similarly, Nigeria's newborn death rate (neonatal mortality) is one of the highest in the world and has been documented to be 528 per day (Ibeh, 2008). Thus, Nigeria contributes 10% to the global mortality rate (Ibeh, 2008;NPC, 2014;WHO, 2012). Research has shown that most of these deaths could be prevented, if women have access to skilled care throughout pregnancy, childbirth and the postpartum period (WHO, 2006).
Varying qualities of health care in different available settings are rendered to women and their newborns. This is an issue of public and reproductive health concern to stakeholders. Poor quality of health care is a major factor contributing to the high maternal, neonatal and child mortality rate in sub-Saharan Africa, particularly Nigeria (Choudhry, 2005). In Nigeria, birthing centres fall into two categories, namely informal and formal birthing centres (Aluko & Oluwatosin, 2008). The informal birthing centres are operated by unskilled birth attendants who have no midwifery training and are therefore not licensed by the Nursing and Midwifery Council of Nigeria (NMCN). These birth attendants are found operating traditional birth attendant centres, faith-based mission homes owned mostly by Christian religious churches. The formal birthing centres are the centres owned by the governments, private individuals or corporate organizations. The major birth attendants are qualified medical or nurse/midwife professionals who have been licensed to undertake maternity care services by the Nigerian Medical Association (NMA) and the NMCN, respectively. Usually, women are encouraged to use formal health facilities for prenatal, natal and postnatal care to avoid the undesirable outcomes associated with pregnancy and childbirth undertaken in informal alternative birthing centres. However, it is worthwhile to appraise the proportion of the teaming population of vulnerable Nigerian women that have access to prenatal care and childbirth services at primary level. On this premise, the study sought to examine whether Nigerian women return to PHC facilities where they initially accessed prenatal care for childbirth services.

| Study design and settings
This clinic-based study employed a descriptive cross-sectional design to evaluate the trends of perinatal care in primary healthcare centres and rate of return to the same centres for childbirth care among postnatal women in an urban centre of South-Western Nigeria. The respondents were recruited across the five Local Government Areas within the Ibadan metropolis. Ibadan is the state capital of Oyo state, Nigeria and the largest city in West Africa sub-region. The city is densely populated with most of the population living in slums and high-density areas.

| Instrument and data collection
The study used a validated self-administered structured questionnaire and a checklist for data collection. The questionnaire, which was designed in line with WHO's "Assessment tool for quality of hospital care for mothers and newborn babies" has four sections (A-D). The 5-item Section A elicited the participants' socio-demographic data, while section B having 17 items elicited participants' obstetric history. Section C assessed participants' experiences at the service centres (WHO, 2010). Thus, the questionnaire was adapted from that of the WHO. The study focused primarily on assessment of return rate for prenatal and childbirth services among Nigerian women. Additionally, section D focused on health workers' attitudes and supports as well as clients' satisfaction with the care they received from at the facilities were examined.
The local language (Yoruba language) version of the questionnaire was produced using "back-to-back" translation and thus was made available to women who could not comprehend English language version. The reliability coefficient of the research tool was 0.8. Thus, it was considered adequate for the study (Creswell & Clark, 2007). In addition, the checklist was used to record the population of women who registered for prenatal care, women who have childbirth care and children brought for vaccination in each of the PHC facilities.
Women who brought their babies for immunization service were recruited to participate in the study. The data collection procedure took place in the waiting areas of child welfare clinics of the PHC facilities. The data collection was facilitated by the healthcare workers in each of the facilities. Data collection spanned four months, and it took 25-30 min for each participant to complete the questionnaire.

| Population and sampling technique
A total of 21 purposively selected PHC facilities within the five Local Government Areas (LGAs) in the urban city. The PHC facilities were purposively selected for the study because they were nearer to women from low socio-economic background and thus vulnerable. The study population were postnatal women who brought their newborns to the PHC centres for immunization against childhood communicable diseases.
The sample size for the surveys was based on Stoker's (1985) table titled "sampling in the quantitative paradigm" (Van Griensven, Moore, & Hall, 2014). This was adopted, being more empirical and easy to adapt for survey studies (Van Griensven et al., 2014). In line with the Stroker's table, the percentage samples recommended for different ranges of population were used for selection of appropriate sample size for PHC centres and the respondents. Therefore, for the estimated total population of 13,437 respondents, 4.5% was recommended by Stoker (Van Griensven et al., 2014). Hence, in this study, 4.5% of 13,437 were calculated to be 604 respondents. In addition, 25% of 604, which was equal to 151 was added for attrition rate. Thus, the sum of 604 samples plus 151 attrition rate amounted to 755 respondents used for this study.
A systematic random sampling technique was used to recruit the 755 postnatal women (clients) from the estimated population of 13,437. The attendance records served as sample frames for the postnatal women. The sample intervals were calculated for the population using the statistical formula: K = N/n, where K = Sample interval; N = Total population in the sample frame; n = sample size (Daniel & Cross, 2010). The sample frame of each PHC centre was used to compute the sample interval.

| IN CLUS I ON AND E XCLUS I ON CRITERIA
These were women whose babies were within day one day 42 or 6 weeks after childbirth, who attended child welfare/immunization clinics and were willing to participate in the study. The women with newborns aged between 1-42 days were included in this study to capture the range of services they were exposed to from pregnancy till puerperium. Besides, it was believed that most of those women would be able to remember nearly all their experiences within six weeks of childbirth. Women who were either not willing or too ill following childbirth were excluded from the study.

| Statistical analytical methods
The population of the prenatal women and the babies was derived from the antenatal and child immunization attendance registers of each PHC facility, respectively. Descriptive and inferential statistics were used for data analysis with the aid of the Statistical Package of Social Sciences (SPSS) version-21. The ages of the women were classified into teenage, matured and elderly mothers.
The classification was based on the associated relative health risks of each category. Paired t tests were performed to establish the degree of statistically significant differences among quality ratings of facilities by participants, between populations of prenatal women versus women who returned to the PHC facilities under study and population of babies immunized versus childbirth undertaken at the PHC facilities under study. Level of significance was reported at 5% probability level.

| Places of prenatal and childbirth care
Out of the 730 women studied, 676 (92.6%) received prenatal care.
The remaining 54 (7.4%) women gave various reasons for not accessing prenatal care. The given reasons are shown in Table 2. Table 3 shows the various healthcare facilities where the 676 women received prenatal care. Disrespectful treatment from health workers in formal centres 1 0.7 Fear of falling into labour at night 3 1.9 In anticipation of emergencies 6 3.9 Just to have access to Tetanus injection 2 1.3 Long waiting time in formal centres 1 0.7 Nearness of the alternative centre 18 11.8 No provision of 24-hr childbirth service in the formal centre 3 1.9 To avoid expensive cost of services in formal centre 2 1.3 To get proper care in formal centre 15 9.9 To have access to both prayer in faithbased & medical care in formal centre 17 11.1 Total 730 100.0 the data were collected (i.e., where they brought their children for immunization as at the time of data collection) to other women.  Table 5.
The women who received childbirth care in various healthcare facilities other than the PHC facilities where data were collected but brought their babies to the later for immunization only (women in category B) rated the two facilities (i.e., the former and the later) on a five-point scale. The six aspects of the facilities that were rated using the five-point scale included environmental hygiene, labour wards, toilets, bathrooms, building appearance and staff attitude. In the rating, the women considered the status of the various health facilities (they considered whether where they gave birth to their babies were better than the places where they were accessing immunization services, that is the PHC facilities where data were collected). The difference was found to be statistically significant (Table 6).
Similarly, the settings where data were collected (the places where the 278 women accessed prenatal and childbirth care but was used by all the participants for child immunization) were rated less than other healthcare facilities (the places where 452 women gave birth to their babies). The difference was found to be statistically significant (Table 6).
There was a statistically significant difference between the mean attendance population of women using antenatal services and that of women returning to the PHC centres for childbirth, p-value < 0.05 (Table 6). This implies that the women who returned to the PHC centres for childbirth were fewer in number than women who received prenatal care in the same centres. Similarly, there was a statistically significant difference between the mean attendance population of women who brought their babies for immunization services and that of women who received childbirth services in the PHC centres, pvalue < 0.05 (Table 6). This implies that women who use other birthing centres (homes, TBA centres, mission homes, private hospitals/ clinics, other government hospitals and maternity centres) but converged at same PHC centres for child immunization were more in number than women who gave birth to their babies in the same PHC centres. Ikeako, and Iloabachie (2006), where women gave reasons for their choice of place of prenatal care and childbirth. Although the women gave reasons akin to those given by the Enugu women for choosing two places for prenatal care, the reported antenatal registration in two different centres was likely to be a sign of indecision about their more preferred place of birth (Creswell & Clark, 2007).

| D ISCUSS I ON
The findings equally revealed that the women rated the other places of childbirth higher than the PHC facilities under study. This implies that most of the women came primarily to the PHC setting for child immunization. This is because other places of childbirth, such as the faith-based centres, traditional birth attendant (TBA) centres and private hospitals do not usually offer immunization services to clients. Onah et al. (2006)  Calabar, South-Southern part of Nigeria, many of the mothers perceived the quality of care they received as satisfactory, while shortage of medications, lack of preparedness for emergencies and long waiting hours were common complaints. It has been argued that dissatisfaction is an indication that services delivered are lacking in some aspects (Rashid & Jusoff, 2009;Rosenthal & Shannon, 1997;Weiss & Rose, 1988). Besides, lack of medications and long waiting hours have been shown to contribute to poor use of services (Katung, 2001;Sauerborn, Nougtara, & Diesfeld, 1989). Therefore, all facilities providing maternity care are to be monitored for compliance with respect to the expected standard of care rendered to women. Rather than discouraging women from receiving care from one facility or the other, improving maternity services in various facilities will likely yield a better outcome. with hygienic toilets and bathrooms will contribute to therapeutic milieu of the women (McLachlan, Forster, Yelland, Rayner, & Lumley, 2008).
The study showed the results of the rating of the health facilities the women used for prenatal and childbirth care. The rating was done on a 5-point Likert scale. The aspects rated by the women included the following: environmental hygiene, labour ward, toilet, bathroom, building appearance and staff attitude.
Other healthcare facilities were rated significantly higher than the PHC facilities under study by those who accessed prenatal and childbirth care in other healthcare facilities. The report of the rating further confirmed that most of the PHC facilities require complete overhaul in respect of the aspects considered in the rating (i.e., environmental hygiene, labour ward, toilet, bathroom, building appearance and staff attitude).
In addition, the study revealed various expressions of dissatisfaction with different aspects of the maternity services by the women.
Those aspects included the following: type of services, condition of building infrastructure, inadequate equipment and medications, attitudes and incompetence of the health workers. All these require prompt attention of the stakeholders.
Apart from that, a situation where pregnant women or postnatal women found no waiting space is dehumanizing and tantamount to abuse of their right to respectful maternal care (Bowser & Hill, 2010). Every woman has the right to be treated with dignity and respect. No one should humiliate or verbally abuse a woman for any reason. Service providers must ensure that women are as comfortable as possible during procedures (Aluko, 2015;Bowser & Hill, 2010). Similarly, it is very discomforting and not dignifying for a woman who has newly been delivered of a baby not to have a place she could empty her bowel, empty her bladder or take her bath despite the usual soiling from vaginal fluid/blood that commonly characterizes labour and childbirth. This unacceptable condition of most of the PHC facilities requires immediate intervention from the appropriate stakeholders. It is a form of denial of human right to dignifying health care because it makes them uncomfortable. Therefore, it must be discouraged (Aluko, 2015;Bowser & Hill, 2010). Consequently, more spacious pieces of land should be sought from the community whenever PHC facilities that are meant to provide maternity services are being considered.
This can improve clients' satisfaction. The various evidences of patient dissatisfaction with the quality of maternity care services that were offered to them in the PHC facilities have been implicated for reduction in use and non-use of formal public healthcare facilities (Phellas, Bloch, & Seale, 2011).
The findings of this study show that the population of women who eventually gave birth to their babies in the studied PHC settings were significantly fewer than those who commenced antenatal care in the centres. Similarly, the population of mothers who brought their babies for immunization was significantly more than the number of mothers who delivered their babies at the PHC facilities. This implies that women who use other health facilities for prenatal care and/or childbirth care converged in the PHC centres for child immunization.
The findings suggest that the PHC facilities require attention and intervention.

| Limitation
Only PHC facilities providing maternity services that are considered as "viable" by management of the LGAs were used for this study. Other facilities that were not designed for maternity services and those that had no regular gynaecological and obstetric patients were excluded based on the recommendations, management of the LGAs.

| Conclusion
From the study, a statistically significant percentage of the women who received prenatal care in the PHC facilities did not return there for childbirth. Similarly, many women who received prenatal care and childbirth care in the PHC facilities would prefer to receive both prenatal and childbirth care in other health facilities during subsequent pregnancies because they were not satisfied with the care received in their last pregnancies. Moreover, the population of women who registered for prenatal care in more than one place was quite large while those who used faith-based healthcare facilities did so to access spiritual care. It might be very difficult to influence them to do otherwise. Besides, the quality rating of the PHC facilities was significantly less than that of the other healthcare facilities. Therefore, the renovation of existing structures and the building of new ones are recommended. In addition, all other dimensions contributing to good quality maternity care services in all other facilities should be evaluated, restructured and monitored for attainment of an acceptable level of quality.

ACK N OWLED G EM ENTS
The authors are grateful to the Centre for Excellent Research, Data Analysis, Consultancy and Training (CERDACT), Nigeria for the expert contributions to the study during data analysis.

CO N FLI C T O F I NTE R E S T
The authors declare no competing interests.

AUTH O R S ' CO NTR I B UTI O N S
AJO initiated and conducted the study, analysed the data and wrote major parts of the manuscript. AR supervised the study and wrote statistically significant parts of the manuscript. She reviewed and edited the manuscript for final submission. MRRM supervised study and wrote statistically significant parts of the manuscript. She reviewed and edited the manuscript for final submission. All authors read and approved the final manuscript. AO supervised the study proposal in preparation for fieldwork. He reviewed and edited the research tools as well as the manuscript.

E TH I C A L A PPROVA L
The study protocol was approved by the Senate of University of

DATA AVA I L A B I L I T Y
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.