Out of health facility delivery is highly challenging and competitive to health facility delivery in many communities in Bayelsa State, as most women continue to engage in the practice. Therefore, the study is to explore in-depth, the factors that influence mothers’ decision to deliver outside health facility where they booked in Bayelsa State. Objectives were to (1) determine personal factors that inform pregnant mother’s decision to deliver outside the health facility of booking, (2) identify family factors influencing out-of health facility delivery, (3) determine institutional factors responsible for their decision to deliver outside the health facility and (4) determine health care providers factors that inform out-of-health facility delivery by pregnant mothers. Transcendental phenomenological research design was adopted, using non-probability sampling technique and purposive sampling methods to obtain data from 15 participants. Validity and reliability was based on criteria for trustworthiness in a qualitative research. Instrument for data collection was semi-structured in-depth interview guide and tape recorder, with an in-depth face-to-face interview that lasted between 10-35minutes (each participant). Data were analyzed using Colaizzi’s seven steps of data analysis, presented in themes, codes and subcodes (Nvivo). Findings revealed interplay of health institutional factors such as attitude of health staff, previous experience of the women, lack of care and support during labour by health care provider, availability of TBA’s and the high cost of delivery services in health facilities. Other findings include socio factors such as distance to health facility, low educational level of respondent and religious beliefs. Significant finding was the women’s expression of fear of Caesarean Section. However, mothers expressed confidence in the antenatal care services where they receive information that both mother and baby is well and safe. Hence, better to deliver at home. Thus, the following recommendations: (i) Raised awareness on danger signs of pregnancy, labour and delivery, (ii) Improve relationship of health care providers and the women (iii) Proper and adequate management system, (iv) Quality assurance policy system and (v) Improving physical access (road access).
Title page                                                                                                        i
Approval page                                                                                                 ii
Certification                                                                                                    iii
Dedication                                                                                                      iv
Acknowledgments                                                                                          v
Table of contents                                                                                            vi
List of tables                                                                                                   viii
Abstract                                                                                                          ix
Background to the Study                                                                               1
Statement of the Problem                                                                               6
Purpose of the Study                                                                                      7
Specific Objectives of the Study                                                                    8
Research Questions                                                                                         8
Significance of the Study                                                                               8
Scope of the Study                                                                                         9
Operational Definition of terms                                                                      9
Concept of Pregnancy and Child birth                                                           11
Theoretical Review                                                                                         23
The Health Belief Model                                                                                23
Empirical Review                                                                                            27
Summary of Literature Review                                                                      35
Research Design                                                                                             37
Study Area                                                                                                      37
Population of study                                                                                        38
Sample Size                                                                                                     38
Sampling procedure                                                                                        39
Inclusion Criteria                                                                                            39
Instrument for Data Collection                                                                       39
Validity of instrument                                                                                    40
Reliability of instrument                                                                                 40
Ethical Considerations                                                                                    41
Procedure for Data Collection                                                                        41
Method of Data Analysis                                                                               42
Presentation of results and Summary of major findings                                 44
Discussion of Findings                                                                                   58
Limitation of the study                                                                                   66
Implication for Nursing                                                                                  66
Suggestions for Further Studies                                                                     67
Summary                                                                                                         67
Conclusion                                                                                                      68
Recommendations                                                                                          69
References                                                                                                      73
Appendices                                                                                                     87
Background to the Study
A pregnant woman needs regular check-ups in a health facility where a midwife or a doctor will be in attendance. These check-ups are called antenatal care or antenatal visit (Iyaniwura & Yussuf, 2009). These check-ups end at delivery of the baby or babies, with post-natal care inclusive. More so, WHO, UNICEF, UNFPA and World Bank (2008), stated that each year about 6 million women become pregnant and 5 million of these pregnancies result in child birth. WHO (2014),  reported that about 16 million girls aged 15-19 and some one million girls under 15 give birth every year, most in low and middle income countries. According to the US Government poster on teen pregnancy, over 1100 teenagers mostly aged 18-19 give birth every day in the United State alone (Hamilton, Brady, Ventura & Stephanie, 2012).
However, pregnancy is complete with three trimester except otherwise. The 1st trimester is the first 13 weeks or 3 months of the pregnancy in which the baby develops at a very fast rate and becomes almost fully formed by the end of it. While the 2nd trimester, is from 4 – 6 months of pregnancy during which it becomes obvious that the mother is pregnant. And the 3rd trimester is from 7 – 9 months until the baby is born. During this period, the baby will build up fat stores, and continue growing rapidly (American Journal of Obstetrics and Gynecology, 2015).
Health Direct Australia (2013), defined antenatal care as the care received from healthcare professional during pregnancy. In light to this, antenatal care (ANC) attendance provides a unique opportunity to improve the health of women and infants. Also, the utilization of ANC provides opportunities of promoting services that may include weight and blood pressure measurement (WHO, 2010). However, distance to health facilities, inadequate Transportation, socio-cultural beliefs and the need for immediate and specialized services have hampered women’s ability to access these services in many less developed countries and northern Nigeria in particular (WHO, 2010).
Antenatal care includes early booking, regular clinic visits as structured and decision to deliver in a health facility at term or otherwise, while Booking is the term used to describe the first visit by the pregnant woman to the antenatal clinic. This first visit which is best during the first trimester provides the opportunity for detailed investigation on the status of both mother and baby. If the mother is expecting her first baby, she will have up to 10 antenatal appointments. If she has a baby before, she will have up to 7 antenatal appointments. Under certain circumstances for example, if you develop a medical condition, you have more visits, (NHS, 2015). Based on the results of a WHO antenatal care randomized trial, the standard measure of adequate antenatal care delivery is a minimum of four (4) antenatal visits (with the first occurring during the first trimester) for a woman and her fetus, if they are judged to be healthy following a standard risk assessment (NHS, 2015). This minimum of 4 antenatal clinic visits throughout full term pregnancy is the package explained in birth preparedness and complication readiness plan.
Birth preparedness and complication readiness plan according to WHO (2005), posited that prenatal care includes attention to a woman’s preparation for child birth such as getting the support she will need from her provider, family and community and making arrangement for her new born. Consequently, the skilled care provider and the woman should plan the following: a skilled provider to be at the birth and how to get there, items needed for the birth and money to pay for the skilled attendance and any needed medications, support after the birth, including someone to accompany the woman to the delivery facility during labour and someone to take care of her family while she’s away. Also an individual birth plan should answer the following questions: Does patient know when baby is due? Has she chosen a skilled health provider? Has she chosen a health facility for delivery? Does she know danger signs in pregnancy? Has she chosen a decision maker? Does she have a transport plan? Has she collected basic birth supplies and does she have a birth partner? If all these answered yes, then the individual is ready for delivery.
Child birth includes both labor and delivery; ie, it refers to the entire process as the baby makes its way from the womb down the birth canal to the outside world (Farlex, 2012). Although, vaginal delivery is the most common and safest type of childbirth, when necessary in certain circumstances, forceps (instruments resembling large spoons) may be used to cup the baby’s head and help guide the baby through the birth canal. Vacuum delivery is another way to assist delivery and is similar to forceps delivery. In vacuum delivery, a plastic cup is applied to the baby’s head by suction and the health care provider gently pulls the baby through the birth canal. However, vaginal delivery may not always be possible, hence Cesarean delivery (C-section) may be necessary for the safety of the mother and baby, especially if one of these complications is present such as big baby, transverse or oblique lie and breech presentation where there will be difficulties for the baby to pass through the pelvis or there is foetal distress. Most often, the need for a cesarean delivery is not determined until after labor begins. Once a woman has had a cesarean delivery, future deliveries may be done by cesarean section. That’s because surgery done on the uterus increases the risk of it rupturing during a future vaginal delivery (Kecia Gaither, 2014). The birth environment has a profound effect on how labour progresses and on how women remember their birth experiences and that the place of birth should provide a distraction-free, comfortable, supportive and reassuring environment for mothers and their families. Women need to remain confident, have freedom to respond to their contractions in any way that works for them and have continuous emotional, psychological, and physical support throughout labour (Lamaze, 2007).
Consequently, a significant proportion of mothers in developing countries still deliver at home unattended by skilled health workers (Montagu, Yamey, Visconti, Harding & Yoong, 2011). In diverse contexts, individual factors including maternal age, parity, education and marital status, household factors including family size, household wealth, and community factors including socioeconomic status, community health infrastructure, region, rural/urban residence, available health facilities, and distance to health facilities determine place of delivery and these factors interact in diverse ways in each context to determine place of delivery (Gabrysch, Cousens, Cox & Campbell, 2011). Van Eijk, Blue, Odhiambo, Ayisi, Blokland and Rosen, et al (2006), looked at antenatal care and delivery care among women in Western Kenya and demonstrated that older women, high parity, lower socioeconomic status, low education levels and more than an hour walking distance were associated with delivery outside health facilities. Studying poor urban dwellers in Nairobi, Fosto, Ezeh and Essendi, (2009), found from bivariate analyses that wealth, education, parity, place of residence were associated with place of delivery. Ochako has previously demonstrated that these factors together with marital status and age at birth of last child determined use and timing of first Antenatal Care (ANC) visit and type of delivery (Ochako, Fotso & Ikamari et al, 2011). There are also wide variations in the reasons women give for delivering at home between and within countries (Sobel, Oliveros & Nyunt, 2010).
Interestingly, in Nigeria, faith has been suggested to be a very important explanation for the utilization of spiritual churches as places of delivery. Non conformity to the tenets of faith may result in sanctions to which defaulting members could be exposed to by their fellow believers. Also the beliefs and fears instilled into members by spiritual churches through prophecies and visions may be contributory (Lawoyin, 2007). Gabrysch and Campbell (2009) argued that socio-cultural beliefs and the need for immediate and specialized services have hampered women’s ability to access services in many low and middle income countries including Nigeria. “Kunya”, or shame play an extremely important role in Hausa childbirth particularly in the first pregnancy. The newly pregnant girl should not draw attention to her state, and all mention of the pregnancy should be avoided in conversation and action. Older women stand ready to scold her. Should her behavior deviate from the expected norm. This social pressure to remain modest may well prevent her from asking questions about seeing antenatal care or to deliver in hospital when labour begins. Wall (1998), observed that the situation in northern Nigeria is critical where strong cultural beliefs and practices on childbirth and fertility-related behaviors partly contribute significantly to the maternal mobility and mortality picture compared to southern Nigeria. From the foregoing, functionalist theory is used for this study. Parson’s (1964), argued that society developed institutions to serve certain functions that are essential to its survival. Such institutions are the family, economic, religion, political, education and health. Society has certain basic needs which must be met for it to survive. These needs are known as functional pre-requisites and the major functions of these social institutions are those which help to meet the functional pre-requisites of the society.
In view of these challenges, the United Nations Millennium Development Goal Five (MDG-5) set a target to reduce maternal mortality by three-quarters between 1990 and 2015 (United Nations Millennium Development Goals Report, 2011). However, as we approach the end of 2015, data from sub-Saharan Africa suggests that the region is only just a third of the way to achieving MDG-5. Statistics from the 2011 Millennium Development Goals Report for sub-Saharan Africa report 640 maternal deaths per 100,000 live births, a decline of 26% from 1990, and a death rate 50-fold higher than that reported by high-income countries (WHO, 2008). Thus, skilled birth attendants are widely accepted as the “single most important factor in preventing maternal death”.
Statement of the Problem
According to Health Direct Australia (2013), antenatal care is the care received from health care professionals during pregnancy in other to achieve positive outcome.
Yet documented evidence reveals that significant proportion of mothers in developing countries deliver at home unattended by skilled health workers, (Montagu, Yamey, Visconti, Harding & Yoong, 2011). A study carried out by Iyaniwura and Yussuf (2009), showed that the availability and accessibility of pregnant women to high quality health care has made maternal death a rare event (1 in 1000 birth), while in the developing countries, the risk of maternal death for a pregnant woman is 1 in every 48 deliveries as a result of availability of low quality health care. In addition, (Gabrysch, Cousens, Cox and Campbell, 2011), stated that in diverse contexts, individual factors including maternal age, parity, education and marital status, household factors including family size, household wealth, and community factors including socioeconomic status, community health infrastructure, region, rural/urban residence, available health facilities, and distance to health facilities determine place of delivery. These factors they further stated interact in diverse ways in each context to determine place of delivery. Incidentally, these factors enumerated above seem to reflect the situation in Central Senatorial District of Bayelsa State.
Also, a study conducted by Babalola (2009), showed that majority of women who delivered outside the health facility under unskilled attendants delivered either in a separate room or inside the house. These deliveries he posited were attended by neighbours, traditional birth attendants, auxiliary nurse and family members, who are usually handicapped in the face of the most basic complications of pregnancy and child birth. This poses a big problem, resulting in many women developing serious complications that may be with them throughout life or cause their death.
In Bayelsa State, pregnant mothers who register for antenatal care still choose to delivery outside health facility where they booked. Some of them choose traditional birth attendants home for delivery instead of skilled birth attendants. The researcher however have observed from Hospital Records in Amassoma Health Centre that about 7 out of 10 pregnant women who booked and have been attending antenatal care deliver outside the health facility, and this seems to be the practice in other health facilities in the state. It was also observed that the numbers of booked pregnant women who choose to deliver outside a health facility are brought back with some complication to the teaching hospitals in Okolobiri from these places to 7 out of every 10 on average (Hospital records, 2015). This necessitates the researcher to carry out the study to evaluate the factors that influences mothers to deliver out-of-health facilities in Bayelsa State.
Purpose of the Study
The purpose of the study is to explore factors influencing mothers’ decision to deliver outside the health facilities they booked for antenatal care in Bayelsa State.
Specific objectives of the Study
The specific objectives guiding this study are to:

  1. Determine personal factors influencing mother’s decision to deliver outside the health facility of booking in the study population.
  2. Identify family factors that influence out-of health facility delivery among the study population.
  3. Determine institutional factors responsible for their decision to deliver outside the health facility, in Central Senatorial District in Bayelsa State.
  4. Determine health care providers factors that inform out-of-health facility delivery by pregnant mothers.

Research Questions

  1. What are the personal factors that informed pregnant mothers to deliver outside the health facility?
  2. What are the family factors influencing their decision to deliver outside the health facility?
  3. What are the institutional factors that influence their decision to deliver out-of-health facility?
  4. What health care provider factors influence relationship between pregnant mothers and care givers during the antenatal visits determine their choice of place of delivery?

Significance of the Study
The findings of this study will provide information on the factors militating against the use of health facility during delivery by pregnant mothers. This will in no doubt help health workers to develop strategies in improving and promoting the knowledge and attitude of mother’s, families and community towards hospital delivery. The data obtained from this study will be used to make recommendations that will increase the number of institutional deliveries and reduce the number of home deliveries. Furthermore, it will help government agencies, health policy decision makers, relevant stakeholders as well as non-governmental agencies in taking appropriate measure to resolving these identified problems, which will in no doubt add to the already existing body of knowledge on ways to improve maternal health services and create room for further studies to expand the scope.
Scope of the Study
The study is delimited to postnatal mothers who booked, attended but delivered their babies outside the health facility of booking. Some uneventful, while some delivered outside and are brought back to the health facility for care in Bayelsa central senatorial district. These facilities include Family Support Programme (FSP) Clinic, Comprehensive Health Centre Agudama-Epie and General Hospital Amassoma. The focus is on personal, family, institutional and healthcare provider factors that informed the out-of-health facility delivery.