Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria

Abstract

BackgroundIn Nigeria, the provision of public and private healthcare vary geographically, contributing to variations in one’s healthcare surroundings across space. Facility-based delivery (FBD) is also spatially heterogeneous. Levels of FBD and private FBD are significantly lower for women in certain south-eastern and northern regions. The potential influence of childbirth services frequented by the community on individual’s barriers to healthcare utilization is under-studied, possibly due to the lack of suitable data.Using individual-level data, we present a novel analytical approach to examine the relationship between women’s reasons for homebirth and community-level, health-seeking surroundings. We aim to assess the extent to which cost or finance acts as a barrier for FBD across geographic areas with varying levels of private FBD in Nigeria.MethodThe most recent live births of 20,467 women were georeferenced to 889 locations in the 2013 Nigeria Demographic and Health Survey. Using these locations as the analytical unit, spatial clusters of high/low private FBD were detected with Kulldorff statistics in the SatScan software package. We then obtained the predicted percentages of women who self-reported financial reasons for homebirth from an adjusted generalized linear model for these clusters.ResultsOverall private FBD was 13.6% (95%CI = 11.9,15.5). We found ten clusters of low private FBD (average level: 0.8, 95%CI = 0.8,0.8) and seven clusters of high private FBD (average level: 37.9, 95%CI = 37.6,38.2). Clusters of low private FBD were primarily located in the north, and the Bayelsa and Cross River States. Financial barrier was associated with high private FBD at the cluster level – 10% increase in private FBD was associated with + 1.94% (95%CI = 1.69,2.18) in nonusers citing cost as a reason for homebirth.ConclusionsIn communities where private FBD is common, women who stay home for childbirth might have mild increased difficulties in gaining effective access to public care, or face an overriding preference to use private services, among other potential factors. The analytical approach presented in this study enables further research of the differentials in individuals’ reasons for service non-uptake across varying contexts of healthcare surroundings. This will help better devise context-specific strategies to improve health service utilization in resource-scarce settings.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3225-4) contains supplementary material, which is available to authorized users.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

“…Although the area's energy sector has generated interest among multi-national companies [71], most Bayelsans remain poor, while the state's public infrastructure is underdeveloped [72,73]. The proportion of women in Bayelsa who cited financial reasons for homebirth is higher than the national average [74]. Under such special economic and environment conditions, wealth may be additionally helpful for overcoming cost of transport, as well as trade-offs in time and financial loss from daily/productive activities.…”

Examining inequalities in access to delivery by caesarean section in Nigeria

“…Use of emergency caesarean section depends on the availability of services that are of sufficient quality. In many rural settings in Nigeria, there are no health facilities [40], and in areas where they exist, the quality of services available is poor, with a lack of consistent supplies, equipment and human resources, especially doctors [21, 41–45]. The problem is further exacerbated by insufficient referral systems and lack of a functioning ambulatory system or a quick alternate transport system [46, 47].…”

Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016

“…In 22 countries, the trend in the poorest quintile was also increasing except in Nigeria and Cameroon where it was decreasing; and stalling in Mozambique. In other countries such as Nigeria, the increased home deliveries among the poorest women in areas of high private sector delivery may suggest a preference to avoid public sector facilities where private sector delivery is unaffordable [37].…”

“…Other reasons include disincentives to use traditional birth attendants at home (eg, in Malawi) [46,47]; increased awareness of the benefits of facility-based delivery [13]; and women’s ability to negotiate use of health services [48,49]. Other studies have also reported that for-profit health care may be more appealing due to a number of reasons such as privacy, shorter waiting times, the quest for high quality of care, availability of doctors and as a symbol of status [37]. The increased number of facility births observed since 2000 provides countries with daunting challenges such as strengthening the generally weak health systems and implementing robust health financing structures, particularly in settings where out of pocket health expenditures are high.…”