"I went to the primary health centre close to my workplace, but their capacity cannot deliver the baby": exploring why women choose different providers for maternal health services in Nigeria.

Abstract

Background: Maternal health remains a significant public health concern globally, including Nigeria. Despite concerted efforts to improve maternal health services, maternal mortality rates in Nigeria remain unacceptably high. Understanding the factors that shape women's choices in selecting the place of birth could help tailor services and improve quality of care for mothers and infants. Therefore, our study explores the experiences, barriers and facilitators that influence where women choose to access maternal health services in three diverse Nigerian states of Lagos, Oyo and Jigawa.

Methods: We conducted qualitative in-depth interviews with nursing mothers and healthcareworkers (HCWs) in Lagos, Oyo and Jigawa states, and community birth attendants (CBAs) in Lagos and Oyo. We used maximum variation sampling to purposefully recruit nursing mothers in their puerperium who gave birth in different places. HCWs and CBAs were purposively selected from health facilities and birth homes. All interviews were conducted between September - December 2023. We used reflexive thematic analysis to generate themes across participant types and states.

Results: We recruited 44 participants for this study, 25 nursing mothers and 19 HCWs. We identified five major themes: (1) Preference for safe, comfortable and quality health services; (2) Social diffusion and cultural/religious influences; (3) Physical, geographical and financial inaccessibility; (4) Symbolic perception of health facilities and (5) Misunderstanding of health promoting and preventive care in pregnancy. The main reasons for choosing a particular place of birth were the preference for safe, comfortable, and high-quality healthcare, as well as the perceived convenience and accessibility of birth homes within close proximity to the women's homes.

Conclusions: We found women's choice of place of birth is influenced by a complex interplay of factors. Among these are health system inadequacies, socio-economic factors, and the desire for comfortable and quality maternal healthcare. HCWs, CBAs, and nursing mothers emphasised these determinants as critical in shaping women's decisions regarding where to give birth. This highlights the need for comprehensive interventions across policy, healthcare delivery, community engagement, and individual levels to overcome barriers, improve maternal health outcomes, and support women in making informed childbirth decisions.