AN ASSESSMENT OF THE UPTAKE OF SKILLED BIRTH ATTENDANT SERVICES AMONG WOMEN OF CHILD-BEARING AGE IN OSISIOMA NGWA LGA

ENCES APPENDIX Appendix 1: Request for ethical clearance letter Appendix 2: Questionnaire LIST OF TABLES Table 1: Socio-demographic characteristics of respondents Table 2: Knowledge of Skilled Birth Attendant Services Table 3: Utilization of Skilled Birth Attendant Services Table 4: Factors affecting the utilization of Skilled Birth Attendant services Table 5: Relationship between utilization of SBA services and outcome of delivery Table 6: association between socio-demographic factors and uptake of skilled birth attendant services Table 7: Association between other factors and utilization of SBA services Table 8: Relationship between uptake of skilled birth attendant services and selected outcomes LIST OF FIGURES Figure1: Bar chart showing utilization of skilled birth attendant services AN ASSESSMENT OF UPTAKE OF SKILLED BIRTH ATTENDANT SERVICES AMONG WOMEN OF CHILD-BEARING AGE IN OSISIOMA NGWA LOCAL GOVRENMENT AREA (LGA) OF ABIA STATE CHAPTER 1 1.0 BACKGROUND Childbirth also known as labor or delivery is the ending of pregnancy where one or more babies leave the uterus by passing through the vagina or by cesarean section [1]. It is a very important process in the course of pregnancy and as such should be handled by appropriately trained personnel. A skilled birth attendant is an accredited health professional such as a midwife, doctor or nurse who has been trained to proficiency in the skills needed to manage uncomplicated pregnancies, childbirth and immediate post-partum period and in the identification, management and referral of complication in women or newborns[2,3]. The use of skilled birth attendant services have been shown to reduce maternal and newborn deaths; and is one of the key indicators monitored in the Sustainable Development Goals (SDGs). [4] Over the years, the utilization of Skilled Birth Attendant services has shown to improve the outcome of pregnancy and delivery and also reduce the incidence of maternal mortality and perinatal morbidity. The Skilled Birth attendant should be able to conduct deliveries in uncomplicated pregnancies, identify and manage obstetric complications and refer the mother or baby to the appropriate health facility if need be. Types of Skilled Birth Attendants include midwives, nurses with midwifery skills, doctors with midwifery skills and obstetricians [2]. The primary cause of maternal deaths is direct obstetric causes that accounts for almost 75% of all maternal deaths viz: Hemorrhage (25%), Pre-eclampsia and eclampsia (16%), Infections (10%), Unsafe abortions (10%), Others (9%).[5,6,7] Most of the deaths due to these complications occur during labor or perinatal period and since the Skilled Birth Attendant can identify these complications early and manage or refer, these deaths can be prevented by the use of Skilled Birth Attendant services. Globally, there were approximately 295,000 maternal deaths in 2017 and 2.5 million neonatal deaths in 2018; nearly 94% of these occur in low resource settings [5, 8]. Studies have shown that 66% of the maternal deaths and 43% of neonatal deaths can be prevented in births that occur with the assistance of a Skilled Birth Attendant. [5, 9]. This is why increasing births assisted by skilled health personnel to 90% is one of the key indicators in the Sustainable Development Goals (SDG). Currently, it is recommended by the WHO that women should have a minimum of 8 visits with skilled health personnel during pregnancy for positive outcomes and experience and five of those contacts should be in the third trimester [10] 1.1 PROBLEM STATEMENT ANC has both direct and indirect effects on maternal health. The direct effects includes early detection and treatment of conditions that lead to poor health outcomes during pregnancy such as hypertension and diabetes; while the indirect effects are through skilled birth attendants which can prevent morbidity/mortality due to emergency conditions that arise during childbirth such as obstructed labor and bleeding. [12] Maternal mortality and neonatal mortality rate are benchmarks for maternal /infant care and the health of a society in general [11]. It is important to understand the consequences of what could follow when there is poor utilization of skilled birth attendants during labor. One in four babies worldwide are delivered without the presence of skilled birth attendants. Every day, hundreds of preventable maternal deaths occur due to pregnancy or child-related complications. Neonatal deaths now account for 44% of the childhood mortality. [4] Some negative delivery outcomes (complications) were significantly associated with non-utilization of skilled birth attendants. Cost, family member’s preference, distance, industrial action and irritation from the vaginal examination were factors that prevented women from using a skilled birth attendant. [13] There are several complications which inadequate utilization of skilled birth attendants can bring about; the primary cause of maternal death is direct obstetric causes that accounts for 75% of all maternal deaths, these obstetric causes are complications that could be avoided if there are proper utilization of skilled birth attendants. Examples of these direct causes are hemorrhage, pre-eclampsia and eclampsia, infections, unsafe abortions and other direct causes such as ectopic pregnancy. [4] 1.2 JUSTIFICATION OF THE STUDY Skilled Birth services have been recognized by numerous studies, bringing to light skilled birth attendance and its importance in decreasing both maternal and neonatal mortality as well as morbidity. The importance of utilizing skilled birth attendance cannot be overemphasized; a study done in Uganda explained the importance of skilled delivery services. This study was carried out to implement skilled birth attendance at birth strategy to help improve maternal care, they wanted to meet a key target of the 5th millennium development goal(MDG) although being a low resource country.[17]WHO recommends skilled delivery services during child delivery to improve maternal and neonatal health.[18, 38] The lack of knowledge on the relevance and importance of skilled birth attendants is an important factor why this study should be conducted. Impoverished families with low level educational background may see no reason for a skilled birth attendant during pregnancy, their lack of knowledge on this matter may end up being one of the reasons why they may face complications during child birth. A study carried out on still birth discussed the effects of providing skilled delivery services, emergency obstetric care and how these services could potentially prevent maternal and neonatal mortality during labor. [35] While Nigeria accounts for only 2% of the world population, it regrettably shares 14% of global maternal death burden. [14] 40 million women of childbearing age in Nigeria (that is women between 15 and 49 years of age) suffer a disproportionately high level of health issues surrounding birth. Although the country represents 2.4% of the world’s population, it currently contributes 10% of global deaths for pregnant mothers. [15] An increase in the proportion of deliveries with skilled birth attendance has been pointed out as an important step to take to reduce maternal mortality and morbidity in developing countries of which Nigeria is one.[39] As of 2018,there was a maternal mortality rate of 576 per 100,000 live births, the fourth highest on earth. Each year approximately 262,000 babies die at birth,[15] In fact a Nigerian woman has a 1 in 22 lifetime risk of dying during pregnancy, childbirth or postpartum/post abortion; whereas in the most developed countries, the lifetime risk is 1 in 4900. [16] Looking at the statistics been stated here, there is need to carry out this study to look at the state of maternal and neonatal health in Osisioma L.G.A. We want to know the range of factors that influence women of reproductive age of this L.G.A to deliver outside healthcare facilities and without the help of skilled birth attendants. This study would help guide maternal services in the right direction as well elucidate a clearer view on the relationship between proper utilization of skilled birth attendance and maternal and neonatal mortality in Osisioma L.G.A. 1.3 RESEARCH QUESTIONS 1. How much do the women of child-bearing age know about Skilled Birth Attendant services in Osisioma Ngwa LGA? 2. How many women utilize Skilled Birth Attendant services in Osisioma Ngwa LGA? 3. What are the factors that may affect the uptake of Skilled Birth Attendant services in Osisioma Ngwa LGA? 4. What is the relationship between uptake of Skilled Birth Attendant services and outcome of pregnancy? 1.4 GENERAL OBJECTIVE To assess the knowledge and utilization of Skilled Birth Attendant services among women of child-bearing age in Osisioma Ngwa LGA. 1.5 SPECIFIC OBJECTIVES 1. To assess the knowledge of Skilled Birth Attendant services among women of child bearing age in Osisioma Ngwa LGA. 2. To assess the percentage of women that makes use of Skilled Birth Attendant services in Osisioma Ngwa LGA. 3. To determine the factors that may affect the uptake of Skilled Birth Attendant services in Osisioma Ngwa LGA. 4. To assess the relationship between uptake of Skilled Birth Attendant services and outcome of pregnancy in the study population. 1.6 HYPOTHESIS TESTING Null Hypothesis: There is no significant association between uptake of Skilled Birth Attendant services and positive outcome of pregnancy. Alternative Hypothesis: There is significant association between uptake of Skilled Birth Attendant services and positive outcome of pregnancy. CHAPTER 2 2.0 OVERVIEW Pregnancy-related deaths are still a leading cause of mortality among women of reproductive age (15-49). In Nigeria, Maternal Mortality Ration (MMR) is still as high as 814 per 100,000 live births. [19] However, scientific evidence has shown that quality obstetric care by a skilled birth attendant will reduce the prevalence of maternal mortality.[20] 20% of all global maternal deaths occur in Nigeria[21] and this may be associated with the relative lack of uptake of skilled birth attendant services in most parts of Nigeria. Research in Sub-Saharan Africa has also shown that lack of knowledge, access and positive attitude towards Skilled Birth Attendant services may be a contributing factor to the high prevalence of maternal and neonatal mortality and morbidity as well as birth complications. World Health Statistics report that as of 2017 an estimated 295,000 to 340,000 maternal deaths occurred yielding an overall MMR of 211 maternal deaths per 100,000 live births, globally.[5] The highest global maternal deaths (196,000) occurred in Sub-Saharan Africa between 2000 and 2017 in as much as there was a 40% decline in maternal deaths in SSA. To expedite the reduction in maternal deaths, WHO accentuates that the utilization of skilled birth attendant services at delivery is indispensable [23] A review of pertinent literature related to the uptake of skilled birth attendant services in the world may shed more light on the trends in the utilization of skilled birth attendance and its impact on maternal mortality. 2.1 KNOWLEDGE OF SKILLED BIRTH ATTENDANCE SERVICES. A descriptive cross-sectional survey was carried out on 654 participants by Girmaye et al. to assess women’s knowledge of skilled assistance services in West Shoa Zone, Oromia Region, Ethiopia. The study found that, with respect to the knowledge score towards skilled maternal health services, 473.3 (72.4%) of the participants had good knowledge and 180.7 (27.6%) had poor knowledge towards skilled maternal health services. [44] Ogboghodo et al. in a descriptive cross sectional study assessed the knowledge of women of childbearing age in Etsako Central L.G.A, Edo State, Nigeria about skilled birth attendant services and the study found that majority of the respondents 457 (98.3%) were aware of SBA and 405 (88.6%) had good knowledge of the importance of SBA services. The researchers concluded that awareness and knowledge of the importance of skilled birth attendant services was relatively good among the study population. [38] Florence et al. in a cross sectional study performed among pregnant women attending antenatal clinic in openzinzi Hciii, Adjumani District, Uganda to assess their knowledge on Birth Preparedness and Complication Readiness found that 71.25% of the respondents showed knowledge of skilled birth attendant services by identifying SBA as a component of Birth Preparedness and Complication Readiness (BPACR). The researchers concluded that the knowledge of BPACR was higher among the educated respondents involved in the study. [27] A community based cross-sectional study carried out in Gibe Wereda, Hadiya Zone and South Ethopia by Fasil et al. found out that out of 728 mothers 192 identified skilled birth provider. The researchers came to the conclusion that there was very low use of skilled birth attendance. [40] Another community based analytical cross-sectional study design was carried out in Benin City, Edo State by Obi et al. they also found out that out of 252 pregnant women, 234 had identified a health facility, 233 identified a skilled birth provider. This study identifies that there was a good knowledge and practice of skilled birth attendance. [41] 2.2 UTILIZATION OF SKILLED BIRTH ATTENDANT SERVICES. A cross-sectional study was conducted between January and April 2017 using structured questionnaires among women in Tharaka Nithi County Kenya. They reported that uptake of skilled birth attendants was 77% (n=345) and non-uptake was 23%..[28] A community- based cross-sectional study was conducted between March 25 to April 24 2017 using pre-tested structured questionnaire among 402 women in Gura Dhamole Woreda, Bale zone southeast Ethopia 2017. They reported that only 29% of women were assisted by skilled birth attendance during their childbirth. Utilization of skilled birth attendance here was low.[29] Another study was conducted among the tribal women of Bangladesh. Data was collected using questionnaires. It was reported that the highest prevalence of delivery (66%) among tribal women occurred at home while 46% of the mothers gave birth to their children with the assistance of a skilled birth attendant. Utilization of skilled birth attendant in this study was poor due to factors such as low level of education among tribal women, socio-economic conditions, distance from health care facilities, husband’s occupation and media exposure.[30] A cross-sectional study using a descriptive sequential mixed method design was conducted between August and December 2016 using structured interview- administered questionnaire among 340 pregnant women in their 3rd trimester in Ogun State. They reported that the utilization of skilled birth attendant services was high (83.8%). There was significant association between the use of skilled birth attendant services and being healthy after delivery. [13] Another study was conducted among women aged 15-49 years who had given birth in 5 years prior to the study (166,022) were included. Data was collected from the most recent demographic and health surveys conducted between January 1, 2010 and December 3, 2018 in 29 countries in Sub-Saharan Africa. It was reported that utilization of skilled birth attendant services was an average of 63%, the highest was in Rwanda (91.2%) and the least was observed in Tanzania (13.8%).This shows that although utilization of the skilled birth attendant services in Sub-Saharan Africa appears high, it is very low in some individual countries such as Ethiopia (30.3%), Niger (32.0%), Nigeria (44.4%) and Togo (45.5%). [24] 2.3 FACTORS THAT AFFECT UTILIZATION OF SKILLED BIRTH ATTENDANT SERVICES A community- based cross-sectional study was conducted between March 25 and April 24 2017 among 402 women in Southeast Ethiopia reported that out of the women who had no formal education (248), 22.8% (58) utilized SBA services while of all women who obtained up to secondary education (33), 81.8% (27) utilized SBA services. 16.9% (30) of the women who attended less than 4 ANC visits (178) utilized SBA services as compared to the 73% (81) out of 111 women who attended 4 or more ANC visits. Time taken to travel to nearby health facility was also a significant factor where the rate of utilization of SBA services increased from those who took up to 2 hours and above; 13% (30) to those who took less than 1 hour; 69.6% (64).[29] Secondary and cross-sectional data was analyzed from the 2014 Bangladesh demographic and health survey (BDHS), in this study, Women with higher than secondary education (688) had the highest percentage of SBA users (65.8%) followed by women who had only secondary education (1407) of which 42.6% utilized SBA. With respect to wealth, the richest set of women were most likely to utilize SBA services where 565 (65.9%) out of 887 women utilized SBA services.[22] Ahinkorah et al analyzed data from the 2018 Guinea demographic and health survey (GDHS) reported that 89.9% of the 552 women who had secondary education or higher utilized SBA services whereas only 50.8% of the women who had no formal education were able to utilize said services. Women within the richest and richer wealth quintile had 95.9% and 82.3% utilization rate out of a total number of 699 and 920 respectively while women within the poorest and poorer wealth quintile had only 42.7% and 30.9% utilization rate out of a total of 1205 and 1116 women respectively. Place of residence was another significant predictor of SBA use in that 91.8% of the 1341 urban dwellers utilized SBA as compared to the 44.0% of rural dwellers (3576) who utilized SBA services. Women who have given birth once had the most utilization rate (69.0%) out of 771 respondents while women who had birthed up to four times had a utilization rate of 51.9% out of 2341 respondents. [32] A study on Determinants of Skilled Birth Attendant Utilization in West Ethiopia reported that monthly income, antenatal care attendance, knowledge of Expected Date of Delivery (EDD) and parity were significant factors that affected the uptake of SBA services. Out of the 83 women who earned over 1500 Ethiopian Birr (ETB) 78.3% gave birth in a health facility as compared to the 26.6% out of 154 respondents that earned below 500 ETB and 53.4% of the 395 women who attended ANC utilized SBA services as compared to the 6.8% of the 73 women who did not attend ANC. 73% of the women who knew their EDD (189) utilized SBA services unlike the 35.4% of 206 women who did not know their EDD. [42] 2.4 RELATIONSHIP BETWEEN SKILLED BIRTH ATTENDANCE AND PREGNANCY OUTCOME A descriptive, study was conducted in Ogun Central senatorial district, Ogun state to ascertain the birth preparedness, utilization of SBA services and delivery outcome among pregnant women. There was significant association between utilization of SBA services and post-partum maternal health as well as the occurrence of maternal complications such as severe bleeding and high grade fever. Out of the 285 women whose births were assisted by a skilled attendant 268 (94%) of the mothers were healthy after pregnancy, 6 (2.1%) experienced severe bleeding while 5(1.8%) experienced high grade fever. There was also significant association between utilization of SBA and the healthiness of the baby (88.4%) as well as perinatal morbidity such as breathlessness (1.8%) and discharge around the umbilical cord (0.0%). [13] A descriptive cross sectional study was carried out by Imaral et al in order to observe the impact of Birth Preparedness and Complication Readiness (BPCR) on maternal and perinatal outcomes. 332 (70.6%) out of 470 respondents who practiced BPCR did not experience maternal morbidity as compared to the 224 (62.7%) out of 357 respondents who did not practice BPCR and 446 (94.9%) of those who practiced BPCR had live births as compared to the 282 (79%) out of the 357 respondents who did not practice BPCR. Out of the 728 live births, 444 were born to mothers who practiced BPCR and 86.9% of them did not experience any perinatal mortality.[33] A retrospective case-control study was conducted in Western Kenya among women of reproductive age (15-49). The study was conducted among a total of 294 cases and 291 controls in order to determine the magnitude of obstetric complications in relation to the use of skilled birth attendance, odds ratio with 95% confidence interval (CI) was computed. Women whose births were assisted by a skilled attendant had an adjusted odds ratio (AOR) of 1.32 with confidence interval (CI): 0.95, 1.84 while those who were assisted by unskilled personnel had an AOR of 0.76 with CI: 0.55, 1.06. [34] A systematic literature search and meta-analysis was done on the impact of Skilled Birth Attendants on stillbirths and perinatal outcomes. A total of 21 studies and 4 reviews were selected for data abstraction. A case-control study from Sudan reported a 25% reduction in still births and neonatal death with training of the village midwives compared to the control with no training, Romans et al. showed a 24% reduction in stillbirths after the introduction of safe motherhood program including skilled birth attendant promotion in Matlab district, Bangladesh. This is contrary to the findings in a quasi-experimental study comparing zones with good access to functioning maternity units (with skilled birth attendants) to zones with no trained skilled attendants, the study showed that the still birth rate in the zones with good access was 22/1000 live births while in the zones with no trained attendants was 16/1000 live births. In a case-control study carried out in Indonesia, provision of skilled attendance at birth in Tanjungsari district showed that the perinatal mortality rate decreased in the intervention district from 50/1000 to 37.4/1000 live births compared to no decrease in perinatal mortality in the control district of Cisalak.[35] Msemo et al. observed 86,624 newborns and documented a sustained 47% reduction in early neonatal mortality within 24 hours and a 24% reduction in fresh stillbirths after conducting the Helping Babies Breathe program for skilled birth attendants. The researchers concluded that implementation of Helping Babies Breathe education program for skilled birth attendants was associated with significant reduction in both early neonatal deaths within 24 hours and rates of fresh stillbirths. [36] Tayebwa et al. observed in a study to determine maternal and perinatal outcomes among Maternity Waiting Home (MWH) users and non-users in Rwanda that maternal morbidity such as post-partum hemorrhage occurred less frequently in MWH users (2.13% of 329 ) than non-users (5.64% of 976) and non-users had more stillbirth than users (7.68% versus 0.91%). [37] CHAPTER 3 3. 0 INTRODUCTION In this chapter, the methodology of this study including the design, sampling technique, study area and population, method of data collection and statistical analysis are discussed. 3.1 STUDY AREA This study was conducted in Osisioma Ngwa LGA, one of the three local governments in the southern senatorial zone of Abia State which is located in the South-east geopolitical zone of Nigeria. Osisioma Ngwa shares boundaries with Ukwa West and Ugwunagbo, Aba South and Aba north, Isiala Ngwa South and Omuma LGA, River State in the south, east north and west respectively. Osisioma Ngwa is located on latitude 7.33 and longitude 5.14 on the world map. It occupies a total area of 198 square kilometers and the current estimated population of Osisioma LGA is 219,632 as at the 2006 national consensus. It is a sub-urban settlement with its headquarters located in Osisioma town mainly populated by members of the Ngwa ethnic group and the Ngwa dialect is predominantly spoken in the region. The predominant religion is Christianity while there are few other traditional sects in the area. Agriculture is the major occupation of the people of Osisioma Ngwa. They are mostly subsistence farmers and grow cassava, oil palm, raffia palm, vegetable etc. Some people rear animals such as goats, sheep, fowl and occasionally cattle, but largely don’t grow crops or rear animals in commercial quantity. Osisioma Ngwa LGA is divided into 10 wards made up of different villages which are subdivided into clans and households called ‘onumara’. The wards include: Umunneise (4 villages), Amavo (8 villages), Aro-Ngwa (8 villages), Amasato (8 villages), Okpu (8 villages), Amator (10 villages), Ama (12 villages) Uratta (16 villages), Umuojima (17 villages), Oso-Okwa (19 villages). [43] 3.2 STUDY DESIGN This is a descriptive, cross sectional study carried out at four selected Wards in Osisioma Ngwa LGA, using self/interviewer administered questionnaire to obtain information with the consent of the study participants. Information was collected on knowledge, utilization, factors affecting utilization of skilled birth attendant services among women of child-bearing age and the relationship between the utilization of skilled birth attendant services and outcome of pregnancy. 3.3 STUDY POPULATION The study was carried out among women of child-bearing age in selected wards in Osisioma Ngwa LGA Abia State. 3.4 SAMPLE SIZE DETERMINATION The sample size was determined using the formula: N = Z2 Pq d2 Where N = minimum sample size Z = standard normal deviation (1.96) P = proportion of desired attribute q = 1-P d = desired level of precision (0.05) And Z =1.96 P = 50% q = 1-P 0.5 d = 0.05 Therefore N = (1.96)2 x 0.5 x 0.5 (0.05)2 N = 384.16 The sample size when corrected for 5% attrition came to 403 3.5 SAMPLING TECHNIQUE The sampling technique used was a multi-staged sampling technique where the selected wards were taken as clusters. In Stage one: Two urban situated wards – Amasato and Umuojima wards and two rural situated wards- Amavo and Aro-Ngwa were selected from Osisioma LGA. Stage two: five villages were selected from each of the four wards by simple random sampling. Stage three: households were randomly selected from each of the five villages. Stage four: women of reproductive age (age 15-49) who have given birth were selected from each household by convenience sampling method. 3.5.1 Inclusion Criteria Women between the ages of 15-49 years as at the time of the study. 3.5.2 Exclusion Criteria - Women who were ill as at the time of the study. - Women who were absent when the study was conducted. - Women who are within the reproductive age range but have not borne any children. 3.6 DATA COLLECTION A self/interviewer administered, semi-structured questionnaire was used to collect information on socio-demographic data, knowledge and utilization of skilled birth attendant services, factors affecting the utilization of skilled birth attendance and the outcome of last pregnancy. The questionnaire was in four sections: section A was about the socio-demographic characteristics of the respondents, sections B and C were about the knowledge and utilization of skilled birth attendant services, section D was about the factors that affect the utilization of skilled birth attendants while section E was about the relationship between utilization of skilled birth attendant services and pregnancy outcome. 3.7 STUDY EQUIPMENT • Questionnaires • Computers 3.8 DATA ANALYSIS The data obtained from the questionnaires post-administration were cleaned analyzed using the software program; Statistical Package for Social Science (SPSS) version 25. 3.9 DATA PRESENTATION The analyzed data were presented using tables and figures. Descriptive analyses were done by calculating relevant means and standard deviations for quantitative variables, while qualitative variables were analyzed using proportion. 3.10 ETHICAL CONSIDERATIONS 1. Ethical approval for the study was obtained from the Ethical committee of Abia State University Teaching Hospital (ABSUTH). 2. Informed consent was obtained from all the participants of this study 3. The integrity of this study is assured 3.11 STUDY LIMITATIONS 1. Financial limitations: the required funds to carry out this study were mildly constrained. 2. Some individuals were unwilling to participate in this study. CHAPTER 4 RESULTS Table 1: Socio-Demographic characteristics of respondents Variable Frequency (N= 403) Percentage (N=100%) Age group of respondents 20 -29 32 7.9 30 -39 248 61.5 40 -49 123 30.5 Religion of respondent Christianity 400 99.3 Islam 3 0.7 ATR 0 0.0 Occupation of respondent Student 17 4.2 Civil servant 70 17.4 Self-employed 234 58.1 Artisan 54 13.4 Unemployed 28 6.9 Educational status of respondents No formal education 39 9.7 Primary 94 23.3 Secondary 154 38.2 Tertiary 116 28.8 Income of respondent Below 30,000 178 44.2 30,000-50,000 146 36.2 Above 50,000 79 19.6 Marital status of respondent Single 18 4.5 Married 351 87.1 Widowed 33 8.2 Divorced 1 0.2 Occupation of respondents' partner Civil servant 93 26.4 Business 100 28.4 Artisan 45 12.8 Self-employed 99 28.1 Unemployed 3 0.9 Clergy 12 3.4 Monthly income of respondents' partner Below 30,000 51 14.5 30,000 -50,000 157 44.6 Above 50,000 144 40.9 Mean age = 33.3  6.3 years Majority of the respondents (61.5%) fall between the ages 26 – 36 years. Most were Christians (99.3%) and married (87.1%). The highest levels of education were tertiary and secondary in 28.8% and 38.2% of the respondents respectively. More than half (58.1%) of the respondents were self-employed, and 44.2% of the respondents had a monthly income of less than NGN 30,000. The occupation of respondents’ partners included Civil servant (26.4%), Self-employed (28.1%) and Business (28.4). 44.6% of the partners earned between N30,000 and N50,000 and 40.9% earned above N50,000. Table 2: Knowledge of Skilled Birth Attendant Services Variable Frequency (N=403) Percentage (N =100%) Have you heard of SBA? Yes 9 2.2 No 346 85.9 Not sure 48 11.9 Source of information about SBA School 1 11.1 Work 0 0.0 Family and friends 7 77.8 Television 1 11.1 If yes, Who is a skilled birth attendant? N = 24 Doctor 6 25 Nurse 9 37.5 Midwife 8 33.3 TBA 1 4.2 Others 0 0 Where can you find a skilled birth attendant N = 28 Hospital 9 32.1 Health centre 9 32.1 Maternity clinic 9 32.1 TBH 1 3.7 Others 0 0 *multiple response Most (85.9%) of the respondents had not heard of Skilled Birth Attendants (SBA), and of those who did, family and friends were the commonest source of the information (77.8%). Most women believed that doctors, nurses, and midwives were SBA with a frequency of 25%, 37.5% and 33.3% respectively, none of respondents believed that no other health worker was a SBA. However, 4.2% of them thought a Traditional Birth Attendant (TBA) was an SBA. When asked where they thought they could find an SBA, all respondents agreed that SBA could be found in the hospital, health centers or maternity. However, only 3.7% believed an SBA could be found in a Traditional Birth home. Table 3: Utilization of Skilled Birth Attendant Services Variable Frequency (N = 403) Percentage (N =100%) Number of deliveries 1-3 183 45.4 4-6 201 49.9 >6 19 4.7 Number of deliveries in a health institution 0 7 1.7 1-3 212 52.6 4-6 172 42.7 >6 12 3.0 Where did you deliver your last child Home 36 8.9 Hospital 142 35.2 Health center 150 37.2 Clinic 68 16.9 TBH 7 1.7 Others 0 0.0 Who assisted in the delivery Doctor 95 23.6 Nurse 147 36.5 Midwife 138 34.2 TBA 22 5.5 Others 1 0.2 Most of the respondents have delivered 3 to 5 times with cumulative percentage of 59.6%. The location of last delivery of respondents included Health center (37.2%), Hospital (35.2%), Clinic (16.9%), Home (8.9%) and Traditional Birth Home (1.7%). A doctor, Nurse, or midwife assisted in the last deliveries of 23.5%, 36.5% and 34.2% of the respondents respectively. Table 4: Factors affecting the utilization of Skilled Birth Attendant services Variable Frequency (N=403) Percentage (N =100%) Age group at last delivery 20 -29 85 21.1 30 -39 267 66.3 40 -49 51 12.6 Distance from nearest health institution Very close 66 16.4 Close 192 47.6 Far 122 30.3 Very far 23 5.7 Cultural beliefs against SBA use Yes 0 0 No 376 93.3 Not sure 403 6.7 Religious restrictions Yes 8 2.0 No 394 97.8 Not sure 1 0.2 Cost restrictions Yes 171 42.4 No 232 57.6 ANC visits Less than 5 221 55.0 More than 5 181 45.0 Majority of the respondents (66.3%) had their last delivery between age 26 – 36 years. 47.6% and 30.3% of the respondents reportedthat the nearest health institutions to their homes are close and far respectively, none of the respondents had any cultural beliefs against use of skilled birth attendant (SBA) services while most of them (97.8%) had no religious restrictions from utilizing SBA services. 42.4% of the respondents have been discouraged from utilizing SBA services due to cost while 57.6% have not. Also, 55% of the respondents attended more than 5 Antenatal Care (ANC) visits during their last pregnancy while the remainder attended less. Table 5: Relationship between utilization of SBA services and outcome of delivery Variable Frequency (N = 403) Percentage (N =100%) Healthy after last delivery Yes 347 86.1 No 56 13.9 Not sure 0 0 Hospital admission N = 56 Yes 45 80.4 No 11 19.6 Not sure 0 0 Blood transfusion N = 56 Yes 35 62.5 No 21 37.5 Not sure 0 0 Oxygen therapy N = 56 Yes 8 14.3 No 39 8.6 Not sure 9 2.0 Fever N = 56 Yes 18 32.1 No 27 48.2 Not sure 11 19.6 Bleeding N = 56 Yes 43 76.8 No 7 12.5 Not sure 6 10.7 Headaches N = 56 Yes 30 53.6 No 17 30.4 Not sure 9 16.1 Lower abdominal pain N = 56 Yes 42 75.0 No 10 17.9 Not sure 4 7.1 Severe weakness N = 56 Yes 31 55.4 No 18 32.1 Not sure 7 12.5 Convulsions N = 56 Yes 2 3.6 No 46 82.1 Not sure 8 14.3 Blurred vision N = 56 Yes 13 23.2 No 27 48.2 Not sure 16 28.6 Alive baby Yes 359 89.1 No 44 10.9 Not sure 0 0 Healthy baby N = 359 Yes 319 88.9 No 40 11.1 Not sure 0 0 Baby admission N = 40 Yes 27 67.5 No 13 32.5 Not sure 0 0 Baby incubation N = 40 Yes 21 52.5 No 19 47.5 Not sure 0 0 Baby transfusion N = 40 Yes 2 5.0 No 37 92.5 Not sure 1 2.5 Baby oxygen therapy N = 40 Yes 19 47.5 No 21 52.5 Not sure 0 0 Baby blue skin N = 40 Yes 6 15.0 No 27 67.5 Not sure 7 17.5 Baby breathless N = 40 Yes 15 37.5 No 18 45.0 Not sure 7 17.5 Baby convulsions N = 40 Yes 0 0 No 29 72.5 Not sure 11 27.5 Most of the respondents (86.1%)were healthy after delivery meanwhile 80.4% of those who were not healthy was admitted into the hospital, 62.5% received blood transfusion, 14.3% received oxygen therapy, 48.2% did not have fever as compared to the 32.1% who did, 76.8% and 75.0% experienced bleeding and lower abdominal pain respectively, 53.6% and 55.4% experienced headaches and severe weakness respectively, most of them (82.1%) did not have convulsions while the majority (48.2%) did not have blurred vision. A greater percentage (89.1%) of the women gave birth to live babies during their last pregnancy and 88.9% of these babies were healthy post-delivery. Out of the ones who were not healthy (11.1%), 67.5% were admitted into the hospital, 52.5% were incubated while the same percentage did not receive oxygen therapy, nearly all of them (92.5%) were not transfused, majority (67.5%) did not have a blue skin discoloration, 37.5% were breathless meanwhile 72.5% experienced no convulsions while the remainder (27.5%) of respondents were uncertain. Table 6: Association between Socio-Demographic factors and Uptake of Skilled Birth Attendant services Variable Skilled birth attendant N (%)a Non-skilled birth attendant N (%)a x P-value Age 20 – 29 28 (85.7) 4 (12.5) 8.165 0.017* 30 -39 231(93.1) 17 (6.9) 40 – 49 103 (83.7) 20 (16.3) Religion Christianity 360 (90.0) 40 (10.0) 1.774 0.183 Islam 2 (66.7) 1 (33.3) ATR 0 (0.0) 0 (0.0) Occupation Student 17 (100) 0 7.082 0.132 Civil servant 65 (92.9) 5 (7.1) Self-employed 212 (90.6) 22 (9.4) Artisan 45 (83.3) 9 (16.7) Unemployed 23 (82.1) 5 (17.9) Educational status No formal education 29 (74.4) 10 (25.6) 15.715 0.001* Primary 81 (82.6) 13 (13.8) Secondary 142 (92.2) 12 (7.8) Tertiary 110 (94.8) 6 (5.2) Monthly income Below 30,000 147 (82.6) 31 (17.4) 18.348 0.000* 30,000-50,000 140 (95.9) 6 (4.1) Above 50,000 75 (94.9) 4 (5.1) Marital status Single 15 (83.3) 3 (16.7) 1.172 0.760 Married 317 (90.3) 34 (9.7) Widowed 29 (87.9) 4 (12.1) Divorced 1 (100.0) 0 (0.0) Partner’s occupation Civil servant 87 (93.5) 6 (6.5) 6.326 0.276 Business 90 (90.0) 10 (10.0) Artisan 41 (91.1) 4 (8.9) Self-employed 89 (89.9) 10 (10.1) Unemployed 2 (66.7) 1 (33.3) Clergy 9 (75.0) 3 (25.0) Partner’s monthly income Below 30,000 44 (86.3) 7 (13.7) 2.580 0.275 30,000 -50,000 146 (93.0) 11 (7.0) Above 50,000 128 (88.9) 16 (11.1) aRow percentage. *Statistically significant p