Interviewer characteristics
This has been described in a previous publication [12].
Participants’ profile
The age range of study participants in the urban area was 24 to 35 years and the median age was 31 years. In the rural area, it was 20 to 34 years with a median age of 26 years. Most of the participants in the urban area, 70% have attained tertiary education while in the rural area, 60% of the participants have had secondary education. Most of the participants in the urban area were on salaried employment while in the rural area most were self-employed.
Decisions concerning where a woman attends antenatal and delivery care
Most of the discussants in the urban and rural areas were of the opinion that the decision on where a woman should obtains antenatal and delivery care should be a joint decision between the man and the woman. They were of the opinion that this approach will make the decision very firm. A participant in the urban area presented her views succinctly:
“This is a family matter and as such the husband and wife should be in agreement on where the woman should attend antenatal care and also deliver her baby” (Discussant, urban area)
Even though most of the participants agreed that it should be a decision made by the man and the woman, among the remaining respondents, some of them were eager to give either party an upper hand in the decision making process. In this regard, most of the participants in the rural area preferred the women having an edge in deciding where a woman should receive antenatal and deliver care. This is how a discussant in the rural area expressed her thoughts:
“It is the woman that should have the final say on where to attend antenatal care and also delivery her baby because it is for her own good since she is the one that is pregnant. In-fact all matters related to safe delivery are centered on the woman and as such she should be more involved in all decisions in such matters” (Discussant, rural area)
Some of the participants in the urban pointed to the very important role of men in matters related to antenatal and delivery which may eventually give them the edge in the making of decisions. This was how one of the participants expressed her thoughts:
“Husbands are important in giving direction, it is their responsibility to give orders especially when things are no longer straight forward like when there is an emergency” (Discussant, urban area)
Another participant related her experience in a way as to portray that the man should have the final say in such matters. This was her narration:
“Husbands have the power to ensure that their wives go for antenatal care. For instance in my first pregnancy, my husband insisted I must go to hospital. I was aware that my mother delivered all her six children including me at home without going to hospital and so was willing to stay at home provided I am not sick till the day I will deliver my baby but my husband insisted I must go to hospital for antenatal care and because of that I registered for antenatal care” (Discussant, urban)
A few of the participants who were in support of a joint decision offered explanations on when it becomes necessary that the woman should be the one to take charge of her health. These were captured in the following two quotes:
“It is the woman and her husband that should decide on when and where the woman should attend antenatal care and deliver the baby but if the husband is one of those men who show ‘I don’t care attitude’ then the woman should take care of herself and if she has the money pay the hospital bills also” (Discussant, rural)
“Some men are stingy and will want their wives to go for antenatal care in places that will cost less or no money. Under such conditions, the woman should be able to make the decision on where she should attend antenatal care and also deliver the baby” (Discussant, urban)
One of the participants in the urban area also pointed out other groups of people who also decide on where women attend antenatal care and also deliver. She named the mother of the woman, mother-in-law and other women in the neighborhood especially those who have experience in matters related to childbirth.
Role of men in antenatal and delivery care
All the participants in the urban and rural communities want intimacy with their husbands whenever they are pregnant. They were of the opinion that the provision of all material and financial needs during the period of pregnancy by the husband should be a ‘settled matter’. The main focus of this intimacy was to ensure they are happy all through the pregnancy period. The thoughts of the women are explained in the following quotes:
“Husbands should always try to make their pregnant wives happy, understand their moods, feel their feelings, show concern and endeavour to reassure the women that all will be well” (Discussant, urban)
“The role of our husbands when we are pregnant is more than financial. They should not provoke us but always try to make us happy, encourage us and provide all forms of support needed for a healthy mother and baby” (Discussant, rural)
A participant in the urban area went further to explain the benefits of intimacy among couples during the pregnancy period. This was how she explained it:
“Physical touch and intimacy of the husband with the wife during pregnancy will ensure that the baby in the womb will share both parents’ blood instead of that of the mother alone if intimacy was absent” (Discussant, urban)
Even though all the participants in the urban and rural communities wanted their husbands to remind and encourage them to attend antenatal care, the two groups of women differed on the subject of husbands accompanying them for antenatal care and during delivery. Most of the participants in the urban area were in favour of husbands accompanying their wives to antenatal care and also be around when they are to deliver. One of the participants had this to say:
“Our husbands should accompany us during antenatal care visits. They should be around us when it is time for delivery, assisting in everything that we may need. In-fact they must not travel when our date of delivery is due” (Discussant, urban)
The reverse was the case for participants in the rural area as almost all of them did not approve of the man accompanying them for antenatal care visits. One of the participants presented her views this way which was chorused yes by all the participants:
“Our husbands should not accompany us for antenatal care, the result of such a mission will be a reduction in the money they give us when we go for antenatal care. We (the pregnant women) will attend our antenatal care ourselves” (Discussant, rural)
The participants in the rural area however had no objections to their husbands accompanying them or being around during hospital visits when the purpose is to deliver.
Places women go for antenatal care and delivery services
Most of the discussants in the urban and rural areas indicated that they attend antenatal care and also deliver their babies at private and government hospitals including primary health centers. However some of the women also patronize maternity homes and traditional birth attendants. The women also pointed out what is relatively unknown that a few women make use of prayer houses and patent medicine vendors for antenatal and delivery care. It was also learnt that some women deliver at home assisted by a birth attendant or any other woman who may be around during the time of delivery.
What determines where a woman should attend antenatal care and obtain delivery services?
Most of the participants in the urban and rural areas were of the opinion that perceived quality of care in a health facility is a major factor the woman considers in deciding on where to register for antenatal care and deliver her baby. This perceived quality of care could be based on the experiences of the woman or following the opinion of other women and cuts across the different classes of health facilities. The experiences of the women were exemplified by the following quotes:
“I prefer to go to a hospital but not just ‘anyhow hospital’ but a hospital with good reputation of taking good care of women and with specialist doctors in the field of Obstetrics and Gynecology who are well trained to manage labour very well” (Discussant, urban)
“The quality of care, in that health facility is important, for instance in my first and second deliveries in a private hospital, the doctors and nurses were very caring, polite and very concerned. They never shouted at me unlike what is seen in the government hospitals. As such I have decided to deliver all my babies there” (Discussant, urban)
It was also found that the community members have a role to play in defining the concept of good quality care and sometimes this may not be based on the concept of a skilled provider. One of the participants had this to say:
“What the community or the women say about a health facility makes us (the pregnant women) to decide whether to deliver there or not. The health workers in some health centers are seen or reputed to be caring and such a report supports delivery in such a facility. In-fact that is why the traditional birth attendants are thriving because our mothers, mothers-in-law and neighbours who have patronized them before spread good news about them in the community and that explains why they are still patronized for antenatal and delivery care in the community till this day” (Discussant, rural)
For a few of the participants, previous experience in a health facility helps in categorizing a particular facility as being of good standard.
“Your previous experience in a health facility has a role to play. In my first pregnancy, I went to antenatal care in a health facility and the doctor did not care. He permitted someone that does not ‘know anything about my pregnancy’ to do vaginal examination and that led to premature rupture of membrane that eventually led to the death of one of my twins. Because of this, I will never go to that health facility or advise anyone to go there” (Discussant, urban)
The cost of delivery is another factor that influences where the woman registers for antenatal care or plan for delivery in the urban and rural areas. One of the participants in the urban area had this to say:
“You know that government and private hospitals do not charge same fees for antenatal and delivery services. So the financial strength of the woman determines whether she will attend antenatal care and deliver in a government or private hospital” (Discussant, urban)
Among the participants in urban and rural areas, closely following cost of services is the proximity of the health facility to the home of the woman. A participant in rural area speaking specifically for delivery services had this to say:
“How close a health facility is to one’s home is very important. I prefer a facility that is close to my home so that anytime labour starts, I don’t need to start arranging for transport, I simply walk to the health facility” (Discussant, rural)
Use of traditional birth attendants for antenatal and delivery care
The participants gave several reasons people still patronize the traditional birth attendants for antenatal and delivery services. However, participants from the rural area emphasized the unique services of traditional birth attendants. A participant who inferred that traditional birth attendants help women achieve conception made this remark:
“In situations where the traditional birth attendant assisted the woman in getting pregnant especially those who had difficulty in conceiving, then they are most likely to attend antenatal care with the traditional birth attendant and also deliver there” (Discussant, rural)
Another participant from the rural area also gave indication that the traditional birth attendants also provide other services apart from antenatal and delivery services which is a plus for their clients. This was how one of the participants made her views known:
“You see, there are some disease conditions associated with pregnancy that requires herbal drugs for complete cure such as “iba’ (referring to malaria) and ‘okpe’ (meaning helminthiasis). Pregnant women who patronize traditional birth attendants are given herbal medicines which help them pass out these diseases in the urine” (Discussant, rural)
Another participant also in the rural area collaborated to this by indicating that the herbal medicines from the traditional birth attendants also cure a form of ‘internal heat’ mostly felt at the pelvic region during pregnancy. She went further to indicate that the herbal medicines have a positive effect on a contracted pelvis. Her view was expressed this way:
“The herbal medicines from the traditional birth attendants when taken by women with contracted pelvis will enable free movement of the pelvic bones during labour thus enabling the women to deliver on their own without an operation” (Discussant, rural)
The participants in the urban area had a different impression of why people patronize the traditional birth attendants. The most important being the good services they provide. This was how a participant made it known:
“The traditional birth attendants know how to deliver good healthcare, they deliver their services in a very friendly manner unlike the public health facilities where the workers are careless and very less concerned in the way they deliver services” (Discussant, urban)
There is also a feeling among the people that the traditional birth attendants are on divine assignment. This was how a participant in the urban expressed her views:
“Some women believe that the traditional birth attendants are naturally gifted to deliver new born babies and that this gift is from God and when people recall that their mothers delivered there safely and women still deliver there safely till today they are convinced that it is the best place to deliver” (Discussant, urban)
The participants in the urban and rural areas also noted that ignorance and lack of money coupled with the high medical bills charged by both public and private health institutions play very key roles on why the women still patronize traditional birth attendants. One participant in the rural area remarked that lack of access roads to health facilities in the rural area also encourage the women to patronize traditional birth attendants.
The opinion of the women of traditional birth attendants
The participants’ views of the services of traditional birth attendants included a criticism of their services. This criticism centered on their inability to manage emergency situations which the participants were aware could occur in pregnancy. This observation was the same among participants in urban and rural communities. A participant in the urban area was quick to focus on issues related to the placenta. She presented her views this way:
“It is not good to patronize traditional birth attendants for delivery services because in case of an emergency, e.g. placenta previa or any other complication they cannot be of assistance and before one could seek help in another place, the woman may be in critical condition or even die” (Discussant, urban)
Perhaps some of the participants were aware of the dangers of bleeding post-delivery and saw this as a deterrent to patronizing the traditional birth attendants for delivery services. These were summarized in the following two quotes:
“There is a problem in going to traditional birth attendants to deliver your baby because in cases of severe bleeding that may necessitate blood transfusion, the traditional birth attendant may not be able to stop the bleeding and cannot transfuse blood also. That means that under such situations, they can do nothing and that is dangerous” (Discussant, urban)
“Even though the traditional birth attendants are good in delivering women of their children, in cases where there is bleeding or convulsion, they cannot really help the woman and that is why going to hospital where there are qualified health workers is better” (Discussant, rural)
One participant also supported this assertion based on her previous experience in labour and emphasized the importance of trained health workers. She shared her experience this way:
“It is good to go to hospital because sometimes complications could arise, for instance in the delivery of my last baby, at a certain point the baby was stock at the birth canal and it took the intervention of the doctors using a ‘force machine’ (meaning a vacuum extractor) to assist me and deliver my baby. That is why I say that trained health workers make the difference, they are better than traditional birth attendants” (Discussant, urban)
One of the participants in the rural area however rose to the defense of the traditional birth attendants emphasizing that they have several remedial measures for some emergencies that may arise during the delivery process. Two participants in urban and four from the rural area were particular about the unhygienic practices of the traditional birth attendants. One participant from the urban area remarked that the traditional birth attendants focus more on the woman with little or no skills for the management of the newborn baby. According to her, they have no equipment to examine the newborn baby and cannot resuscitate the baby if the need for that arises. Another participant in the urban area was spiritual in her approach to the activities of the traditional birth attendants. She presented her views this way:
“Some of the traditional birth attendants may be operating with a ‘bad spirit’ which they can pass on to the child during the delivery process and this can affect the child adversely” (Discussant, urban)
Reasons why women deliver at home
Most of the participants in both the urban and rural areas identified lack of finance as the major reason why women deliver their babies at home. Most of the participants were of the opinion also that the hospital bills in both government and private hospitals are too high thus worsening the financial situation. These were how the women expressed their views:
“Lack of money and most times, no means of even going to the hospital make people to deliver at home. Some women instead of suffering themselves and their families will prefer to leave everything in the hand of God hence deliver their babies at home” (Discussant, urban)
“Most of the women who deliver at home do so because of financial problems. You see the economy is not good and some of the hospitals charge very high bills for delivery which they cannot afford and because of this many will just deliver at home” (Discussant, rural)
A close scrutiny may reveal that this concept of no money is individually defined and may be due to low priority placed on delivery. A participant had this to say about a friend and home delivery:
“Some people deliver at home mainly due to lack of money. My colleague though she works in a hospital delivered all her children at home due to the high bills charged for delivery in our hospitals” (Discussant, urban)
Perhaps, this matter of money limiting access to delivery services in hospitals prompted one of the participants to plead with the government to subsidize hospital delivery fees or make it completely free. She had this to say:
“I think that the government should subsidize antenatal and delivery services or make it free so that those running away from our hospitals due to financial problems can easily access care” (Discussion, urban)
Another participant in the urban area viewed all these excuses around money limiting access to antenatal and delivery services as due to ignorance. She remarked about her friend this way:
“My friend claimed that her mother delivered all of them (seven) at home, and being her child, she inherited that characteristic and as such she has no need for antenatal care and delivery in a hospital. So she delivers her children at home” (Discussant, urban)
Another major reason for delivering at home was related to culture. It is perceived that a true woman does not need the assistance of anyone to deliver a baby. One of the participants likened this to the Fulani women who due to their culture can bear pain and hence deliver easily at home. They however pointed out this is more prevalent in the rural areas. This was how this information was collaborated by participants in urban and rural area:
“Some said that delivery at home shows strength hence any woman who delivers her baby at home is seen as a strong woman and will be praised by the people especially the elderly women in the community” (Discussant, rural)
“In some villages, they view the women going to deliver in hospitals as being weak and that if anyone goes to a hospital to deliver, the doctors and nurses will install fear in the person. Child birth is a proof of womanhood hence a true woman delivers at home” (Discussant, urban)
Closely related to the cultural influence in limiting access to delivery services is the demystification of pregnancy and delivery by women after passing through the experience. In this regard, the women now view pregnancy as normal issue they could handle on their own. One of the participants presented her thoughts this way:
“Some women who have delivered more than two children feel that it is no longer useful going to the hospital to deliver since they are now used to labour and delivery and because they now have confidence in themselves will prefer to deliver at home” (Discussant, urban)
One participant was fatalistic in her submission on where a woman is supposed to deliver her baby. She admitted in her words:
“It is God that has the final say on where a woman will deliver her baby and if she has been destined to deliver at home, no matter how long she stays in the hospital she will still not deliver there until she goes back home” (Discussant, rural)
The other reasons proffered by the participants on why women deliver at home looked more like excuses. A participant in the urban was of the opinion that home delivery could be incidental in that while the woman may be preparing to go to the hospital labour may start unannounced and she may end up delivering at home. Another participant from the rural area blamed health workers for their poor judgements of labour. She explained that sometimes a woman maybe in active labour but the health worker will tell her to go home and she will eventually deliver at home. Another participant also from the rural area showed a good understanding of the labour process and linked that to delivery at home by the women. She had this to say:
“Some women have ‘precipitate labour’ and even though they are willing to go to hospital and also have money to pay the hospital bills they may eventually deliver at home because labour started abruptly” (Discussant, rural)
A participant from the urban area remarked that in some communities in the rural area the health facilities are not easily accessible and based on this some women may deliver at home.