“I went to the primary health centre close to my workplace, but their capacity cannot deliver the baby”: Understanding factors influencing choice of providers for maternal health services in Nigeria

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Akinsola, Julius Salako, Risikat Quadri, Olabisi Olasupo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4931243/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 15 You are reading this latest preprint version Abstract Background Maternal health remains a significant public health concern globally, particularly in low- and middle-income countries such as Nigeria. Despite concerted efforts to improve maternal health services to achieve the Sustainable Development Goal of less than 70 maternal deaths per 100,000 live births by 2030, maternal mortality rates in Nigeria remain unacceptably high. Understanding the factors that shape women's choices in selecting the place of delivery could help tailor services and improve quality of care for mothers and infants. Therefore, our study seeks to understand the experiences, barriers and facilitators influencing where women choose to access maternal health services in three diverse Nigerian states: Lagos, Oyo and Jigawa. Methods We conducted a qualitative study using in-depth interviews with nursing mothers, healthcare workers in Lagos, Oyo and Jigawa states, and traditional birth attendants (TBAs) in Lagos and Oyo. We used maximum variation sampling to purposefully recruit nursing mothers in their puerperium who delivered in different places. Healthcare workers and TBAs were purposively selected from birth health facilities and birth homes. We used reflexive thematic analysis to generate themes across participant types and states. Results 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 choice of place of delivery were 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 delivery is influenced by a complex interplay of factors. Prominent among these are health system inadequacies, socio-economic influences, and the desire for comfortable and quality maternal healthcare. Healthcare providers, TBAs, and nursing mothers emphasised these determinants as critical in shaping their 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. Maternal health services place of delivery nursing mothers healthcare workers traditional birth attendants Background Maternal health remains a significant public health concern globally, particularly in low- and middle-income countries such as Nigeria ( 1 ). Despite concerted efforts to improve maternal health services to achieve the sustainable development goal (SDG) of less than 70 maternal deaths per 100,000 live births by 2030, maternal mortality rates in Nigeria remain unacceptably high ( 2 ). The 2023 UN report on Trends in Maternal Mortality from 2000–2020 reported a global maternal mortality ratio (MMR) of 223 maternal deaths per 100 000 live births. Nigeria had the highest estimated number of absolute deaths at 82000 annually, and proportion of the global burden (28.5%). While this represents a 34% decline since the year 2000, progress has been too slow ( 3 , 4 ). SDG 3 was structured with interventions to achieve universal health coverage by ensuring equitable access to quality essential health services including maternal health services and family planning as core pillars of safe motherhood ( 5 – 7 ). However, only 52% of women attend the recommended minimum of four antenatal visits and 38% delivered in a healthcare facility in Nigeria ( 3 , 8 – 11 ). In Nigeria, many efforts have been made by government and development partners to improve maternal health service delivery and utilisation. For instance, Nigeria’s Health Sector Renewal Initiative aims to comprehensively revamp physical infrastructure, equipment and retraining of frontline health workers ( 12 ). The redesign of the Basic Health Care Provision Fund (BHCPF) should further enhance access to essential healthcare services, reduce costs and improve access by allocating resources more equitably to the poorest and most disadvantaged populations ( 13 ). The ‘save the million lives’ project was also executed by the Federal Government of Nigeria – as a maternal, newborn and child health (MNCH) programme supported by the World Bank to catalyse change in the way health business is done ( 14 ). It was effective in increasing government awareness of critical MNCH indicators, especially in States where the programme was implemented. ( 15 ). Access to quality antenatal and delivery health services is crucial to reduce maternal and child deaths. However, despite these initiatives, according to the 2018 National Demographic Health Survey (NDHS), only 43% of pregnant mothers had a skilled birth attendant at delivery. Studies have shown that women continue to face multifaceted challenges in determining where they will give birth ( 16 , 17 ). Understanding the factors that shape women's choices in selecting the place of delivery could therefore improve service provision, and help in achieving better health outcomes for both mothers and infants ( 18 , 19 ). Previous quantitative studies conducted in Nigeria have shown challenges impacting health-seeking behaviours and choice of maternal healthcare provider include: inadequate healthcare infrastructure, socioeconomic disparities, policy and governance shortcomings, proximity to health facilities and maternal education and awareness programs in influencing healthcare-seeking behaviours, healthcare quality and accessibility issues, and cultural and societal norms ( 9 , 18 , 20 – 24 ). However, there are limited qualitative studies which provide a deeper understanding of the complex socio-cultural, economic, and health system factors that shape choice of maternal healthcare provider in the Nigerian context ( 25 ). Therefore, our study seeks to understand the experiences, barriers and facilitators influencing where women choose to access maternal health services in three diverse Nigerian states: Lagos, Oyo and Jigawa. These findings can help inform targeted interventions, like creation of outreach programs that are sensitive to cultural differences or the identification of areas where infrastructure needs to be improved to facilitate accessibility to improve maternal health outcomes. Methods Study design We conducted a qualitative study using reflexive thematic analysis with in-depth interviews with nursing mothers and healthcare workers in Lagos, Oyo and Jigawa., and traditional birth attendants (TBAs) in Lagos and Oyo ( 26 ). All interviews were conducted between September 2023 and December 2023. These states represent different socio-cultural contexts, health infrastructure, and levels of urbanisation, providing a rich tapestry of experiences and perspectives. We followed the Consolidated Criteria for Reporting Qualitative Research guidelines for reporting of this study ( 27 ). Conceptual framework We used the Andersen’s model of health service utilisation to inform the development of our interview guide. The model consists of predisposing, enabling and need factors ( 28 ). In the model, predisposing factors encompass demographic, social, and cultural characteristics that predispose women to seek or avoid maternal healthcare services. Enabling factors refer to the resources and opportunities that facilitate or hinder maternal healthcare access and utilisation. Need factors reflect the perceived or actual need for maternal healthcare care ( 28 ). Setting We conducted the study in Lagos and Oyo in the south-west, and Jigawa in the north-west geopolitical zones of Nigeria. Lagos state is the most populous state in Nigeria with an estimated population of 24.6 million people in 2022 and is an economic hub in West Africa. We recruited participants from Ikorodu Local Government Area (LGA), which is a peri-urban and the majority of people are of the Yoruba ethnic group, with small/medium-scale entrepreneurship as the predominant economic activity. The literacy level in Lagos state is 85.3% and 93.0% for women and men, respectively. According to NDHS, 86.4% of pregnant women utilised ANC by a skilled health provider, and 75.7% had health facility deliveries ( 15 ). In Lagos, 75% of the people are in the wealthiest quintile and the MMR was 430 per 100,000 ( 15 , 30 ). In Oyo State, participants were recruited from two LGAs: Ibadan southwest and Lagelu in Ibadan metropolis, which is the capital of Oyo state. Ibadan is an ancient city with 5 urban and 6 peri-urban LGAs, and the majority of people are of the Yoruba ethnic group. The literacy level in Oyo state is 85.3% and 90.2% for women and men, respectively, 85.4% of pregnant women utilise ANC by skilled health providers, and 70.1% had a health facility delivery ( 15 ). In Oyo 38.5% of the people are in the wealthiest quintile and 262 MMR per 100,000 live births annually, below the national average ( 15 , 31 ). Jigawa state is an agrarian setting with an estimated population of 7.9 million people. Participants were selected across two LGAs: Dutse and Kiyawa. The majority of people are of the Hausa ethnic group, and the literacy level is 18.1% and 58.1% for women and men, respectively. 78.6% of pregnant women utilise ANC by skilled health providers, and 20.1% had a health facility delivery in Jigawa ( 15 ). In Jigawa, 4.0% of the people in the Jigawa are in wealthiest quintile and the MMR is estimated to be 1,012 per 100,000 live births Jigawa ( 15 , 29 ). Participants and sampling We used purposive maximum variation sampling to recruit nursing mothers in their puerperium who delivered in different places (mission homes, TBAs, primary health centres (PHCs), secondary health facility (SHF) and were of different age groups and levels of education. For healthcare workers, various primary health workers (nurses and community health officers) who have different levels of education and work experience were recruited for this study. TBAs were purposively selected from mission homes and traditional birth homes, who have provided maternal health services (antenatal and/or delivery) with different levels of education and work experience (Tables 1 and 2 ). These participants were independently approached by the researchers for participation in the study. We did not interview TBAs in Jigawa for this study, as they have been incorporated into the PHC system, and thus do not offer unsupervised or independent maternal health care services. Table 1 Summary Statistics of Participants’ Characteristics (Health care providers) Healthcare providers Characteristics Lagos (N = 7) Oyo (N = 6) Jigawa (N = 6) Gender Female 7 6 6 Profession Community health worker 0 2 0 Nurse 4 1 6 TBA 3 3 0 Level of care Community (TBA) 3 3 0 Primary 3 4 1 Secondary 0 0 2 Tertiary 0 0 1 Private 0 0 2 Level of education Primary 0 1 0 Secondary 3 2 0 Tertiary/Postgraduate 4 3 6 Religion Islam 3 0 4 Christianity 4 6 2 Table 2 Summary Statistics of Participants’ Characteristics (nursing mothers) Nursing mothers Characteristics Lagos (N = 7) Oyo (N = 5) Jigawa (N = 13) Level of education No education 0 0 5 Primary 0 0 1 Secondary 5 3 5 Tertiary/Postgraduate 2 2 2 Religion Islam 4 3 12 Christianity 3 2 1 Data collection The interviews were conducted face-to-face at the participant’s home or in a private place at their place of work depending on the participant’s preference and convenience. All interviews were audio-recorded. Interviews in Lagos were conducted by OO, in Oyo by KOA and OB, and in Jigawa were conducted by JS and RS, JS, RS and OB are research nurses with experience in qualitative interview techniques, OO has a bachelor’s degree with experience in qualitative interview techniques and KOA is a female researcher with a master’s degree and experience in qualitative research. They are all fluent in English language and local dialects (Hausa and Yoruba). The interviewers had no personal relationship with the participants. We did not conduct repeat interviews. Transport fare/inconvenience fare was given as incentive to all participants. An in-depth interview guide was used to explore perception, motivation, barriers influence choice of place of antenatal care and delivery services. (see Appendix 1). Data analysis The analysis team included KOA, OE, RQ and AAB. KOA and JS independently reviewed transcripts for completeness and accuracy. An inductive thematic analysis was conducted utilising the Braun and Clarke reflexive thematic analysis approach ( 26 ). The first step was data familiarisation, then OE, RQ and KOA blindly coded the data and generated descriptive codes in the first round. Codes were then categorised, and the team collaboratively reviewed categories and created themes. The theme generation process was iterative, involving several rounds of discussion and refining among the entire team. Ethics Prior to interviewing and recording participants, we obtained verbal and written informed consent ensuring anonymity and confidentiality. Participants were allowed to withdraw at any time and were informed that the interviews were for research purposes. All data is being stored at Oxygen for Life Initiative according to data management regulations. We received approval from Jigawa state Ministry of Health (ref: JGHREC/2023/152), Lagos state University Teaching hospital (ref: NHREC04/04/2008) and UI/UCH ethics committee (ref: UI/EC/22/0311). Results We identified four 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; ( 5 ) Misunderstanding of health promoting and preventive care in pregnancy. Preference for safe, comfortable and quality health services Participants emphasised their preference for safe, comfortable, and high-quality healthcare services as key considerations influencing their choice of delivery location. In Oyo State, nursing mothers expressed concerns regarding the proficiency of healthcare workers (HCWs) and the apparent shortage of experienced personnel, particularly in PHCs. This shortage raised doubt about the competence of HCWs in PHCs to provide maternal health services, including the management of pregnancy-related complications, and scepticism about the quality of care available. This directly impacted trust in PHCs, prompting a preference for childbirth in secondary and tertiary health facilities. Similar sentiments were shared by nursing mothers in Lagos, who consistently expressed a preference for general hospitals and tertiary hospitals with readily available medical staff. This preference was largely driven by the perception that these hospitals possess the expertise necessary to handle potential childbirth complications. The presence of doctors, in particular, was cited as a crucial factor, instilling reassurance and confidence in women about the quality of care they would receive. I went to the PHC close to my workplace, but their capacity cannot deliver the baby (Nursing mother 05 OYO) They (government hospitals) have good hands, they have qualified hands (specialist in every area) that can attend to people (Nursing mother 01 LAGOS) However, several nursing mothers expressed concerns regarding the pathway to care in secondary and tertiary level facilities, particularly the long waiting times and bureaucratic processes encountered during service utilisation. As expressed by one these challenges deter women from selecting facilities for childbirth. The hectic protocol of Adeoyo (SHF), where you will have to be going from one place to the other. I ran away from the stress that they gave us there (Nursing mother 03 OYO) Poor infrastructure and limited medical supplies were challenges repeatedly mentioned by nursing mothers and healthcare workers as influencing the choice of place of delivery. In Oyo and Jigawa, nursing mothers and HCWs raised concerns regarding the lack of 24-hour services in PHCs, with a gap in access to care during nighttime hours. This lack of round-the-clock services raised significant apprehensions among nursing mothers while they were pregnant, as they recognized the unpredictable nature of pregnancy journeys. With the possibility of going into labour at any time, the absence of nighttime services in primary healthcare centres presented a potential barrier to accessing timely and necessary care during childbirth. In Jigawa, nursing mothers added the lack of toilet facilities as a major factor they consider while choosing a place for delivery. This finding shed light on the practical concerns of hygiene and comfort that women weigh in when making such a critical decision. Some women don’t come to give birth in the PHCs because of privacy, we don't have toilets for ANC clients and you know most pregnant women do urinate a lot and would be going to that outside toilet like 3 to 4 times before they go home and their toilet is not clean. Some women urinate outside. One also told me that people do get infected with different diseases because they used our toilet (HCW 01 JIGAWA) I went to a PHC to enquire, and they said they don’t do night (provide 24 hours services). So, I had to look for another place (Nursing mother 04 OYO) The poor attitude of HCWs in government owned/formal health facilities was an issue repeatedly highlighted by nursing mothers in Oyo and Jigawa. Nursing mothers reported discouraging interactions and disrespectful attitudes from HCWs during antenatal care visits, which subsequently deterred them from opting for facility-based childbirth at government facilities, and to some choosing private hospitals. Specifically, they valued the respectful treatment and attentive care provided by healthcare workers in private hospitals and expressed a preference for these facilities. This positive experience motivated their trust in private facility-based childbirth. When I went to deliver at the general hospital, I was there for over an hour without being attended to. I was crying in pain and begging them to attend to me, then she (the health worker) came with anger and poured insults on me but in the private hospital, the doctor and the nurse were all on my head till I delivered, and they were petting me and talking to me so calmly. I like the way the private hospital treats me, and I like the way they allow my husband to enter into the labour room with me. I prefer to deliver at a private hospital (Nursing mother 03 JIGAWA) Social diffusion and cultural/religious influences In Oyo, we found significant social dynamics influencing decision-making with birth experiences shared by other mothers’ a key consideration. Nursing mothers who had previous live delivery experiences at non health facility-based settings (TBAs, mission homes) recounted positive experiences associated with home and community births, citing factors such as safe childbirth, familial support and privacy that come with the birthing process. This was re-enforced by the diffusion of information within their social circles with stories of successful home births within their community encouraging them to choose the same path. Additionally, cultural and religious influences surrounding childbirth, coupled with longstanding traditions of relying on TBAs for delivery assistance, further influenced women's decision to deliver at home. My pastor’s wife had her 1st born and second born here (TBA). She didn’t say anything bad about this place. She said they attended to her very well that when she’s pregnant again there’s nobody that will tell her before she comes back, she was even the one that gave me courage to come here (Nursing mother 01 OYO) Nursing mothers in the three states frequently highlighted spousal support in decision-making processes for where they would give birth. Specifically, joint decision-making within the family was reported to favour different locations in all states - births at mission homes or traditional birth homes and residential home. They emphasised that the decision of where to deliver was not solely made by the individual woman but rather involved input and consensus from the husband. I wanted a private hospital. My husband approved of me going to a private hospital, but I also talked about it with his uncle too, who said he doesn’t want us to go to a private hospital. Although his nephew (my husband) wanted a private hospital, he(uncle) was not in support of us going to a private hospital. When I was pregnant, he told us not to go early for antenatal until he later approved of private hospital (Nursing mother 03 OYO) In Jigawa, personal comfort and cultural norms influenced women's preferences for the gender of healthcare providers during childbirth. Their husbands generally were against male HCWs providing services to their wives and the older women were not comfortable with being attended to or treated by younger female HCWs as this was perceived to be a threat to their self-esteem. Some (husbands) don't allow their wives to come to the hospital because there are no female doctors here . Also, s ome women said because the nurses in the ANC unit are younger nurses. That some of the nurses are even more like their grandchildren so they don't want “small children of yesterday” to come and be palpate them and see their nakedness (HCW 01 JIGAWA) Physical, geographical and financial inaccessibility Nursing mothers and healthcare workers in Lagos and Oyo repeatedly mentioned limited transportation options as challenges for women residing far from healthcare facilities. This lack of accessible transportation options was said to present a considerable obstacle for these women, as it hindered their ability to reach healthcare facilities in a timely manner when in labour. Consequently, many women felt compelled to resort to home delivery or sought assistance from community birth attendants or mission homes for childbirth. She (pregnant woman) said, yesternight when she was falling to labour, the husband was not around, and there was no means of transportation to reach here (PHC facility), and nobody was ready to take her here (HCW 02 OYO) When it rains, it is very crazy on this road and makes it very difficult to transport myself to the health facility (Nursing mother 01 LAGOS) Among nursing mothers in Lagos, Oyo and Jigawa states, distance from formal health facilities emerged as a prominent factor motivating them to opt for home deliveries and other non-facility deliveries. This was particularly pronounced in rural areas where healthcare facilities were often situated far from communities. The perceived convenience and accessibility of TBAs within close proximity to their homes played a pivotal role in shaping women's preferences for home births. The distance from the home is far far from healthcare facilities which the reason I make use of this place (TBA’s) is because it’s closer to my house. (Nursing home 02 LAGOS) Economic factors such as financial constraints influenced decisions on choice of place of delivery as well, with some women opting for home births, delivery at mission homes as the cost of formal healthcare was too high. HCWs and nursing mothers in three states confirmed this factors, but there was also a notable mention of nursing mothers seeking the assistance of community or traditional birth attendants, not only for financial reasons but also due to the empathy and understanding they offered. Some women don't have the money for a bike to go to the hospital. In such a situation it is only when the women are having challenges with the pregnancy, they would think of accessing any facility that is most close to them if not those women that are ok, they won't go anywhere (HCW 01 JIGAWA) I chose to deliver with the help of a traditional birth attendant not just because it was more affordable, but also because they truly understand and care for us in ways that made me feel supported and respected (Nursing mother 01 OYO) Symbolic perception of health facilities In Jigawa, participants expressed the prevailing cultural belief that home delivery signifies in their words, “show of strength” which fostered hesitation towards facility delivery. Also, healthcare facilities are predominantly perceived as a recourse for managing complications during childbirth, rather than as a primary option for delivery. Our culture demands women to show her strength by giving birth alone at home without going to the hospital. Some women because of this culture they would manage their labour alone and deliver alone in their room. It is when she pushes her baby out before she will call for help, especially multigravida (HCW 03 JIGAWA) Conversely, nursing mothers in both Lagos and Oyo states voiced significant concerns regarding fear of caesarean section as a deterrent to secondary facility-based childbirth. Specifically, they expressed apprehension about medical procedures and potential adverse outcomes during childbirth which deeply influenced their decision-making process, leading some women to opt against secondary facility-based childbirth. I used to be fearful of general hospital because I think that everybody that goes to general hospital must undergo a surgical procedure (Nursing mother 02 LAGOS) Lack of awareness about the benefits of hospital births and ignorance about the possible complications that may arise from delivery at a non-health facility-based institution clearly influenced decision-making among some nursing mothers in Jigawa state. Our results revealed a general lack of understanding among nursing mothers about the potential risks and complications that could arise during childbirth outside of a healthcare facility. Honestly, I don’t think they do tell us about the dangers of not giving birth in the hospital, except if they do say it but I wasn’t there. They don’t even tell us to come to the hospital and even if they do tell others, I don’t know but they did not say I should come back to give birth to the best of my knowledge (Nursing mother 01 JIGAWA) Misunderstanding of health promoting and preventive care in pregnancy HCWs highlighted the misinformation around haematinics (drugs that improve blood quality or quantity by increasing haemoglobin levels and red blood cell count such as folic acid) being issued at the facility during ANC that women in Jigawa believe can increase the size of their babies. This makes them avoid health facilities for ANC antenatal care. Similarly, in Oyo nutrition during pregnancy is believed to promote macrosomia (a condition where a newborn has an excessive birth weight) which may lead to caesarean section. Some women don't want to come for ANC because they believe that iron supplements and folic acid are making babies to be big inutero. So they won't come so that they won't be given the drugs (HCW 01 JIGAWA) We observed that some wombs are large as they (women) eat. You know what we eat is what the baby eats as well in the womb. The way the baby sees the food is the way the baby eats it. Therefore, it will increase the weight of the baby, so we would tell them when you want to eat, take liquid food like pap and drink a lot of water (TBA 02 OYO) Discussion Our study sought to understand the experiences and perceptions that influence women’s choice of where they access maternal health services in Lagos, Oyo and Jigawa. We found motivations for choice of place delivery are complex and contextual. Infrastructural deficits and limited HCW capacity deter women from utilising PHCs, while bureaucratic processes were barriers to service utilisation in secondary hospitals. In Jigawa, delivery at home is regarded as a show of strength and hospital delivery is culturally unusual, while misconceptions about nutrition in pregnancy were also described as preventing uptake of ANC services. Consistent with prior qualitative research in Nigeria ( 23 , 32 ) our study reveals widespread concerns among women regarding the expertise and availability of healthcare workers in PHCs. The perceived shortage of skilled personnel and poor infrastructure in PHCs significantly undermines women's confidence in these facilities for childbirth, leading them to prefer higher-level institutions perceived to offer better quality care. Our findings indicate that pregnant women prefer to choose a trusted and dependable facility for planned delivery which can accommodate their needs reliably at any time of day, facilities where 24-hour services are being offered and not affected by strikes. Investment in healthcare workforce, infrastructure improvement and robust monitoring are recommended to enhance women's confidence in utilising primary healthcare centres for childbirth in Nigeria ( 33 ). WHO recommends a global target of at least 90% of all births being attended by a skilled birth attendant ( 34 ). Although the SDG indicator 3.1.2 - Proportion of births attended by skilled health personnel does not have an explicit SDG target. The SDG global target says, it is expected that it reaches a ‘universal’ coverage level, meaning that every woman gets this support at the time of birth ( 35 ) Despite the efforts Nigerian has put in place, more effort is needed to achieve this. Efforts towards implementing the 2024 Nigeria health sector renewal investment initiative on comprehensive revamp of physical infrastructure, equipment and retraining of frontline health workers and Basic Health Care Provision Fund (BHCPF) redesigned to enhance access to essential healthcare services as outlined in the National Health Act (2014) should include women and communities perspectives to promote their uptake of maternal health services ( 11 ). In addition to the lack of night shifts influencing women's maternal healthcare decisions, our study underscores the persistent infrastructural deficit in PHC facilities in Nigeria. Despite government initiatives aimed at revamping PHCs, such as the National Primary Health Care Development Agency (NPHCDA) revitalization program, our findings suggest that these efforts have not yielded tangible and sustained improvements in healthcare accessibility and quality at the grassroots level ( 36 ). This highlights a critical gap in translating policy initiatives into impactful outcomes on the ground. The continued infrastructural challenges, including inadequate facilities, equipment, and staffing, significantly hinder the provision of essential maternal healthcare services at the primary care level. Therefore, alongside addressing financial barriers, urgent attention is needed to strengthen PHC infrastructure and ensure sustained support for revitalization initiatives to effectively enhance maternal health services and outcomes in Nigeria. The challenges women faced within healthcare settings, such as long waiting times, bureaucratic processes, and inadequate infrastructure, resonate with other studies which reported barriers to accessing maternal healthcare services ( 1 , 24 ). This highlights that pregnant women place significant importance on factors like comfort and a stress-free environment with hygiene and sanitary facilities, when selecting a location for receiving antenatal care and delivering their babies. While these factors deter women from seeking facility-based childbirth, they also highlight systemic deficiencies that need to be addressed through targeted healthcare system improvements in Nigeria ( 37 , 38 ). Similarly, the negative experiences reported by nursing mothers in our study, including disrespectful attitudes from healthcare workers in government-owned facilities, corroborate findings from previous research ( 39 , 40 ). This underscores the critical role of patient-provider interactions and the impact of healthcare worker attitudes on women's healthcare-seeking behaviour. Our study showed that provider-patient relationships and the quality of interpersonal care emerge as critical determinants influencing women's choices of healthcare facilities for childbirth. This requires a systemic solution including review of preservice training. Anecdotal evidence suggests HCWs are subjected to abusive treatment during pre-service training, an unfriendly training environment which might have shaped their perception about client relationships ( 41 ). Therefore, efforts towards improving healthcare worker training and fostering a culture of respectful and empathetic care are essential steps towards enhancing women's trust in utilising health facility-based maternity services ( 42 , 43 ). Furthermore, the influence of social dynamics, cultural norms, economic constraints, and limited transportation options on women's childbirth decisions is consistent with findings from other studies in Nigeria ( 44 , 45 ). Financial considerations are a crucial factor that often dictate women's decisions regarding healthcare utilisation, highlighting the need for targeted interventions to address economic disparities and enhance accessibility to maternal healthcare services ( 46 ). Cultural factors such as community norms surrounding childbirth, has been revealed as an influential determinant shaping women's preferences for home births or facility-based care. It showed that the desire of women particularly in the northern part of Nigeria to be perceived as strong women within their community emerged as a dominant influence on their decision-making. This is similar to the findings from a study in Africa reporting that home birth makes a real woman ( 47 ). This cultural value appeared to outweigh considerations of the risks associated with home delivery versus the benefits and safety offered by facility-based deliveries ( 48 , 49 ). Community engagement and culturally sensitive healthcare approaches are essential for addressing these factors and promoting appropriate maternal healthcare seeking and utilisation behaviours ( 50 , 51 ). The symbolic perception of health facilities and false beliefs about nutritional supplements among pregnant women in Jigawa present complex challenges for maternal healthcare utilisation and preventive care. The observation that misinformation, particularly regarding supplement use during pregnancy, significantly influences women's decisions to avoid hospital births reflects a critical barrier to accessing essential maternal health services ( 51 , 52 ). The false belief that taking supplements could reduce foetal size highlights a fundamental misunderstanding of prenatal nutrition and its impact on foetal development. This misconception likely stems from broader symbolic perceptions of health facilities and healthcare practices, contributing to a disconnect between health-promoting behaviours and preventive care ( 53 , 54 ). Furthermore, the assumption that nutrition causes intrauterine growth restriction, anaemia, and increased negative outcomes underscores the urgent need for targeted education and interventions to dispel myths and promote evidence-based practices. Addressing these misconceptions requires a multi-faceted approach that engages healthcare workers, community leaders, and traditional birth attendants to deliver accurate information and culturally sensitive maternal health education ( 55 , 56 ). By challenging false beliefs and enhancing trust in healthcare services, we can empower pregnant women in Nigeria to make informed decisions that optimise maternal and foetal health outcomes ( 57 ). Limitation One of the limitations in this study is that nursing mothers may have felt compelled to provide responses they believed were expected or viewed favorably, particularly when interviews were conducted within healthcare facilities. This bias could have led some women to express more positive opinions about the facilities than they genuinely felt. To minimize this, we conducted the interviews in a private place and assured participants that interview is confidential. Conclusion We found women’s choice of place of delivery is influenced by a complex interplay of factors. Prominent among these are health system inadequacies, socio-economic influences, and the desire for comfortable and quality maternal healthcare. Healthcare providers, TBAs, and nursing mothers highlighted these factors as critical in shaping their decisions regarding where to give birth. The implications of these findings call for multifaceted interventions at the policy, healthcare delivery, community engagement, and individual levels to overcome the barriers and promote safer, more comfortable, and accessible maternal healthcare services. By addressing these challenges, healthcare systems can work towards achieving better maternal health outcomes and ensuring that women have the support and resources needed to make informed decisions about childbirth location based on their preferences and needs. Declarations Consent for publication Not Applicable Availability of data and materials The datasets used and/or analysed during the current study are not publicly available due to privacy restrictions of the participants but are available from the corresponding author on reasonable request. Competing interest There are no conflicts of interest to declare. Funding This project is a self-funded project. Authors’ contribution AAB, KOA, and AGF conceived and designed the study. KOA, OB, OO, JS and RS were involved in data collection with oversight from AAB and AGF. KOA, OE, RQ, JS and AAB analysed the data. KOA and AAB drafted the manuscript with inputs from CK and AGF. All authors read and approved the final version of the manuscript. Acknowledgments We thank the data collectors, and study participants for their time and support. References Ajegbile ML. Closing the gap in maternal health access and quality through targeted investments in low-resource settings. J Glob Heal Reports [Internet]. 2023 Oct 13 [cited 2024 Mar 12];7:e2023070. https://doi.org/10.29392/001c.88917 UNICEF. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]., 2023 [cited 2024 Mar 25]. https://www.who.int/publications/i/item/9789240068759 WHO. Maternal mortality rates and statistics - UNICEF DATA [Internet]. 2023 [cited 2024 Mar 25]. https://data.unicef.org/topic/maternal-health/maternal-mortality/ Olamijulo JA, Olorunfemi G, Okunola H. Trends and causes of maternal death at the Lagos University teaching hospital, Lagos, Nigeria (2007–2019). BMC Pregnancy Childbirth [Internet]. 2022;22(1):1–12. https://doi.org/10.1186/s12884-022-04649-4 WHO. New global targets to prevent maternal deaths [Internet]. 2021 [cited 2024 Apr 10]. https://www.who.int/news/item/05-10-2021-new-global-targets-to-prevent-maternal-deaths UNICEF. SDG Goal 3. Good Health and Well-being - UNICEF DATA [Internet]. 2024 [cited 2024 Apr 10]. https://data.unicef.org/sdgs/goal-3-good-health-wellbeing/ WHO. Targets of Sustainable Development Goal 3 [Internet]. 2024 [cited 2024 Apr 10]. https://www.who.int/europe/about-us/our-work/sustainable-development-goals/targets-of-sustainable-development-goal-3 Adewoyin Y, Odimegwu CO, Bassey T, Awelewa OF, Akintan O. National and subnational variations in gender relations and the utilization of maternal healthcare services in Nigeria. PAMJ. 2022; 4228 [Internet]. 2022 May 12 [cited 2024 Mar 25];42(28). https://www.panafrican-med-journal.com/content/article/42/28/full Adedokun ST, Uthman OA, Bisiriyu LA. Determinants of partial and adequate maternal health services utilization in Nigeria: analysis of cross-sectional survey. BMC Pregnancy Childbirth. 2023;23(1):1–11. UNICEF. Delivery care - UNICEF DATA [Internet]. 2024 [cited 2024 Apr 10]. https://data.unicef.org/topic/maternal-health/delivery-care/ UNICEF. Antenatal care - UNICEF DATA [Internet]. 2024 [cited 2024 Apr 10]. https://data.unicef.org/topic/maternal-health/antenatal-care/ WHO. 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Abuja, Nigeria, and Rockville, Maryland, ; 2019 - Google Search. 2018; https://www.google.com/search?q=National+Population+Commission+%28NPC%29+%5BNigeria%5D%2C+ICF.+Nigeria+Demographic+and+Health+Survey+2018.+Abuja%2C+Nigeria%2C+and+Rockville%2C+Maryland%2C+USA%3A+NPC+and+ICF%3B+2019&source=hp&ei=mDmjYc77Da-GjLsPwMewIA&ifls Kifle MM, Kesete HF, Gaim HT, Angosom GS, Araya MB. Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea. J Heal Popul Nutr [Internet]. 2018 Oct 22 [cited 2024 Mar 13];37(1):1–15. https://link.springer.com/articles/ 10.1186/s41043-018-0153-1 Yahya MB, Pumpaibool T. Factors influencing the decision to choose a birth center by pregnant women in Gombe state Nigeria: Baseline survey. J Heal Res. 2019;33(3):228–37. Abad N, Uba BV, Patel P, Barau DN, Ugochukwu O, Aliyu N et al. A rapid qualitative assessment of barriers associated with demand and uptake of health facility-based childhood immunizations and recommendations to improve immunization service delivery in Sokoto State, Northwest Nigeria, 2017. Pan Afr Med J [Internet]. 2021 [cited 2024 Jan 8];40(Suppl 1):10. Available from: /pmc/articles/PMC9475061/. Adedokun ST, Uthman OA. Women who have not utilized health Service for Delivery in Nigeria: Who are they and where do they live? BMC Pregnancy Childbirth. 2019;19(1):1–14. Ajayi AI, Ahinkorah BO, Seidu AA. I don’t like to be seen by a male provider: health workers’ strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria. Int Health. 2023;15(4):435–44. Victor Kyari G, Zubairu Tajo A, Ruth John C, Ibrahim M, Micah D, Istifanus Anekoson J, et al. Determinants of the Choice of Healthcare Services During and After Pregnancy in Some Selected Rural Areas in Kaduna. Sci World J [Internet]. 2020;15(4):2020. Available from: www.scienceworldjournal.org. Mekwunyei LC, Odetola TD. Determinants of maternal health service utilisation among pregnant teenagers in delta state, nigeria. Pan Afr Med J. 2020;37(81):1–17. Adedokun ST, Uthman OA. Women who have not utilized health Service for Delivery in Nigeria: Who are they and where do they live? BMC Pregnancy Childbirth [Internet]. 2019 Mar 13 [cited 2024 Apr 10];19(1):1–14. https://link.springer.com/articles/ 10.1186/s12884-019-2242-6 Akaba GO, Dirisu O, Okunade KS, Adams E, Ohioghame J, Obikeze OO et al. Barriers and facilitators of access to maternal, newborn and child health services during the first wave of COVID-19 pandemic in Nigeria: findings from a qualitative study. BMC Health Serv Res [Internet]. 2022;22(1):1–14. https://doi.org/10.1186/s12913-022-07996-2 Omer S, Zakar R, Zakar MZ, Fischer F. The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan. Reprod Health [Internet]. 2021;18(1):1–12. https://doi.org/10.1186/s12978-021-01151-6 Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Heal [Internet]. 2019;11(4):589–97. https://doi.org/10.1080/2159676X.2019.1628806 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Heal Care [Internet]. 2007 Dec 1 [cited 2024 Apr 10];19(6):349–57. https://dx.doi.org/10.1093/intqhc/mzm042 ANDERSEN R. The value of a salicylate-free analgesic following dental surgery. Curr Ther Res - Clin Exp. 1970;12(10):645–7. Sharma V, Brown W, Kainuwa MA, Leight J, Nyqvist MB. High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method. BMC Pregnancy Childbirth. 2017;17(1):1–6. Wright KO, Fagbemi T, Omoera V, Johnson T, Aderibigbe AA, Baruwa B, et al. A population-based estimation of maternal mortality in Lagos State, Nigeria using the indirect sisterhood method. BMC Pregnancy Childbirth. 2024;24(1):1–6. NURHI. Family planning/ Childbirth spacing services advocacy kit. Oyo state. 2011;9. Oluwakemi OE, Feyisola AO, Alero RA, Omowunmi BQ. Choice of Healthcare Facilities for Antenatal Care, Delivery Services and Satisfaction Received by Mothers of Infants in Lagos, Nigeria. Afr J Health Sci. 2024;36(4):348–61. Zajac S, Woods A, Tannenbaum S, Salas E, Holladay CL. Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Front Commun. 2021;6(March):1–20. World Health Organization. Defining competent maternal and newborn health professionals. 2018. 1–42 p. United Nations Children’s Fund. DELIVERING FOR WOMEN: Improving maternal health. 2022;3–6. Aigbiremolen AO, Alenoghena I, Eboreime E, Abejegah C. Primary Health Care in Nigeria: From Conceptualization to Implementation. J Med Appl Biosci [Internet]. 2014 [cited 2024 Apr 23];6(2277–0054). https://www.researchgate.net/publication/269703981_Primary_Health_Care_in_Nigeria_From_Conceptualization_to_Implementation Kifle MM, Kesete HF, Gaim HT, Angosom GS, Araya MB. Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea. J Heal Popul Nutr. 2018;37(1):1–15. Puthussery S, Bayih WA, Brown H, Aborigo RA. Promoting a global culture of respectful maternity care. BMC Pregnancy Childbirth [Internet]. 2023;23(1):1–3. https://doi.org/10.1186/s12884-023-06118-y Orpin J, Puthussery S, Davidson R, Burden B. Women’s experiences of disrespect and abuse in maternity care facilities in BenueState, Nigeria. BMC Pregnancy Childbirth. 2018;18(1):1–9. Doctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. Health facility delivery in sub-Saharan Africa: Successes, challenges, and implications for the 2030 development agenda. BMC Public Health. 2018;18(1):1–12. Fukkink R, Helmerhorst K, Gevers Deynoot-Schaub M, Sluiter R. Training Interaction Skills of Pre-service ECEC Teachers: Moving from in-Service to Pre-service Professional Development. Early Child Educ J [Internet]. 2019;47(4):497–507. http://dx.doi.org/10.1007/s10643-019-00928-6 Umar N, Quaife M, Exley J, Shuaibu A, Hill Z, Marchant T. Toward improving respectful maternity care: A discrete choice experiment with rural women in northeast Nigeria. BMJ Glob Heal. 2020;5(3):1–10. Muhayimana A, Kearns I. Healthcare Providers ’ Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers. in Five Hosp Rwanda. 2024;1–18. Fagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: Evidence from a population-based survey. Reprod Health. 2015;12(1):1–9. Ahuru RR. Maternal Care Utilization in Primary Healthcare Centers in Nigerian Communities. Community Heal Equity Res Policy. 2022;42(3):325–36. Olonade O, Olawande TI, Alabi OJ, Imhonopi D. Maternal mortality and maternal health care in Nigeria: Implications for socio-economic development. Open Access Maced J Med Sci. 2019;7(5):849–55. Dahlberg M, Södergård B, Thorson A, Alfvén T, Awiti-Ujiji O. Being perceived as ‘a real woman’ or following one’s own convictions: a qualitative study to understand individual, family, and community influences on the place of childbirth in Busia, Kenya. Cult Heal Sex. 2015;17(3):326–42. Owigho O, Isara A. Women’s perception of quality and utilization of antenatal care and delivery services in Oshimili South Local Government Area of Delta State, Nigeria. J Community Med Prim Heal Care. 2022;34(1):81–98. Kanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub-Saharan Africa: Evidence from nationally representative health facility assessments. J Glob Health. 2017;7(2). Udenigwe O, Okonofua FE, Ntoimo LFC, Imongan W, Igboin B, Yaya S. Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria. BMC Pregnancy Childbirth. 2021;21(1):1–14. Salmanu RA, Odetola TD. A community-based intervention study for enhancing Hausa women’s knowledge about maternal healthcare services. Int J Africa Nurs Sci [Internet]. 2024;20(February):100669. https://doi.org/10.1016/j.ijans.2024.100669 Nwankwo CU, Ezenwaka CE. The barriers preventing pregnant women from accessing midwife-led antenatal care in Nigeria. J Nurs Educ Pract. 2020;10(5):36. Ope BW. Reducing maternal mortality in Nigeria: addressing perception and Reducing maternal mortality in Nigeria: addressing perception and experience of maternal health services experience of maternal health services Fig. 1. Figure 1. Framework for assessing q. J Glob Heal Rep [Internet]. 2020;4:e2020028. Available from: www.icmje.org/coi_disclo-. Fleary SA, Ettienne-Gittens R, Heffer RW. Perceptions of Preventive Health Care and Healthy Lifestyle Choices for Low Income Families: A Qualitative Study. ISRN Prev Med. 2013;2013:1–6. Adatara P, Afaya A, Baku EA, Salia SM, Asempah A. Perspective of Traditional Birth Attendants on Their Experiences and Roles in Maternal Health Care in Rural Areas of Northern Ghana. Int J Reprod Med. 2018;2018:1–10. Miller T, Smith H. Establishing partnership with traditional birth attendants for improved maternal and newborn health: A review of factors influencing implementation. BMC Pregnancy Childbirth. 2017;17(1):1–10. Amutah-Onukagha PD, Rodriguez MPHN, Opara MPHM, Gardner MPHMSWI, Assan MPHM, Hammond BSMA. Progresses and Challenges of Utilizing Traditional Birth Attendants in Maternal and Child Health in Nigeria. Int J Matern Child Heal AIDS. 2018;6(2):130–8. Additional Declarations No competing interests reported. Supplementary Files InterviewguideANCstudy1.1.pdf Cite Share Download PDF Status: Published Journal Publication published 25 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 17 Oct, 2024 Reviews received at journal 15 Oct, 2024 Reviews received at journal 15 Oct, 2024 Reviews received at journal 14 Oct, 2024 Reviews received at journal 12 Oct, 2024 Reviewers agreed at journal 05 Oct, 2024 Reviewers agreed at journal 02 Oct, 2024 Reviewers agreed at journal 01 Oct, 2024 Reviewers agreed at journal 07 Sep, 2024 Reviewers agreed at journal 05 Sep, 2024 Reviewers invited by journal 26 Aug, 2024 Editor invited by journal 21 Aug, 2024 Editor assigned by journal 19 Aug, 2024 Submission checks completed at journal 19 Aug, 2024 First submitted to journal 17 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Despite concerted efforts to improve maternal health services to achieve the sustainable development goal (SDG) of less than 70 maternal deaths per 100,000 live births by 2030, maternal mortality rates in Nigeria remain unacceptably high (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The 2023 UN report on Trends in Maternal Mortality from 2000\u0026ndash;2020 reported a global maternal mortality ratio (MMR) of 223 maternal deaths per 100 000 live births. Nigeria had the highest estimated number of absolute deaths at 82000 annually, and proportion of the global burden (28.5%). While this represents a 34% decline since the year 2000, progress has been too slow (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSDG 3 was structured with interventions to achieve universal health coverage by ensuring equitable access to quality essential health services including maternal health services and family planning as core pillars of safe motherhood (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, only 52% of women attend the recommended minimum of four antenatal visits and 38% delivered in a healthcare facility in Nigeria (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In Nigeria, many efforts have been made by government and development partners to improve maternal health service delivery and utilisation. For instance, Nigeria\u0026rsquo;s Health Sector Renewal Initiative aims to comprehensively revamp physical infrastructure, equipment and retraining of frontline health workers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe redesign of the Basic Health Care Provision Fund (BHCPF) should further enhance access to essential healthcare services, reduce costs and improve access by allocating resources more equitably to the poorest and most disadvantaged populations (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The \u0026lsquo;save the million lives\u0026rsquo; project was also executed by the Federal Government of Nigeria \u0026ndash; as a maternal, newborn and child health (MNCH) programme supported by the World Bank to catalyse change in the way health business is done (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It was effective in increasing government awareness of critical MNCH indicators, especially in States where the programme was implemented. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccess to quality antenatal and delivery health services is crucial to reduce maternal and child deaths. However, despite these initiatives, according to the 2018 National Demographic Health Survey (NDHS), only 43% of pregnant mothers had a skilled birth attendant at delivery. Studies have shown that women continue to face multifaceted challenges in determining where they will give birth (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Understanding the factors that shape women's choices in selecting the place of delivery could therefore improve service provision, and help in achieving better health outcomes for both mothers and infants (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious quantitative studies conducted in Nigeria have shown challenges impacting health-seeking behaviours and choice of maternal healthcare provider include: inadequate healthcare infrastructure, socioeconomic disparities, policy and governance shortcomings, proximity to health facilities and maternal education and awareness programs in influencing healthcare-seeking behaviours, healthcare quality and accessibility issues, and cultural and societal norms (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, there are limited qualitative studies which provide a deeper understanding of the complex socio-cultural, economic, and health system factors that shape choice of maternal healthcare provider in the Nigerian context (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Therefore, our study seeks to understand the experiences, barriers and facilitators influencing where women choose to access maternal health services in three diverse Nigerian states: Lagos, Oyo and Jigawa. These findings can help inform targeted interventions, like creation of outreach programs that are sensitive to cultural differences or the identification of areas where infrastructure needs to be improved to facilitate accessibility to improve maternal health outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study using reflexive thematic analysis with in-depth interviews with nursing mothers and healthcare workers in Lagos, Oyo and Jigawa., and traditional birth attendants (TBAs) in Lagos and Oyo (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). All interviews were conducted between September 2023 and December 2023. These states represent different socio-cultural contexts, health infrastructure, and levels of urbanisation, providing a rich tapestry of experiences and perspectives. We followed the Consolidated Criteria for Reporting Qualitative Research guidelines for reporting of this study (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eConceptual framework\u003c/h2\u003e \u003cp\u003eWe used the Andersen\u0026rsquo;s model of health service utilisation to inform the development of our interview guide. The model consists of predisposing, enabling and need factors (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In the model, predisposing factors encompass demographic, social, and cultural characteristics that predispose women to seek or avoid maternal healthcare services. Enabling factors refer to the resources and opportunities that facilitate or hinder maternal healthcare access and utilisation. Need factors reflect the perceived or actual need for maternal healthcare care (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eWe conducted the study in Lagos and Oyo in the south-west, and Jigawa in the north-west geopolitical zones of Nigeria.\u003c/p\u003e \u003cp\u003eLagos state is the most populous state in Nigeria with an estimated population of 24.6\u0026nbsp;million people in 2022 and is an economic hub in West Africa. We recruited participants from Ikorodu Local Government Area (LGA), which is a peri-urban and the majority of people are of the Yoruba ethnic group, with small/medium-scale entrepreneurship as the predominant economic activity. The literacy level in Lagos state is 85.3% and 93.0% for women and men, respectively. According to NDHS, 86.4% of pregnant women utilised ANC by a skilled health provider, and 75.7% had health facility deliveries (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Lagos, 75% of the people are in the wealthiest quintile and the MMR was 430 per 100,000 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Oyo State, participants were recruited from two LGAs: Ibadan southwest and Lagelu in Ibadan metropolis, which is the capital of Oyo state. Ibadan is an ancient city with 5 urban and 6 peri-urban LGAs, and the majority of people are of the Yoruba ethnic group. The literacy level in Oyo state is 85.3% and 90.2% for women and men, respectively, 85.4% of pregnant women utilise ANC by skilled health providers, and 70.1% had a health facility delivery (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Oyo 38.5% of the people are in the wealthiest quintile and 262 MMR per 100,000 live births annually, below the national average (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eJigawa state is an agrarian setting with an estimated population of 7.9\u0026nbsp;million people. Participants were selected across two LGAs: Dutse and Kiyawa. The majority of people are of the Hausa ethnic group, and the literacy level is 18.1% and 58.1% for women and men, respectively. 78.6% of pregnant women utilise ANC by skilled health providers, and 20.1% had a health facility delivery in Jigawa (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Jigawa, 4.0% of the people in the Jigawa are in wealthiest quintile and the MMR is estimated to be 1,012 per 100,000 live births Jigawa (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and sampling\u003c/h2\u003e \u003cp\u003eWe used purposive maximum variation sampling to recruit nursing mothers in their puerperium who delivered in different places (mission homes, TBAs, primary health centres (PHCs), secondary health facility (SHF) and were of different age groups and levels of education. For healthcare workers, various primary health workers (nurses and community health officers) who have different levels of education and work experience were recruited for this study. TBAs were purposively selected from mission homes and traditional birth homes, who have provided maternal health services (antenatal and/or delivery) with different levels of education and work experience (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These participants were independently approached by the researchers for participation in the study. We did not interview TBAs in Jigawa for this study, as they have been incorporated into the PHC system, and thus do not offer unsupervised or independent maternal health care services.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary Statistics of Participants\u0026rsquo; Characteristics (Health care providers)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eHealthcare providers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLagos\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOyo\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJigawa\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity health worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity (TBA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary/Postgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary Statistics of Participants\u0026rsquo; Characteristics (nursing mothers)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eNursing mothers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLagos\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOyo\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJigawa\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary/Postgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e The interviews were conducted face-to-face at the participant\u0026rsquo;s home or in a private place at their place of work depending on the participant\u0026rsquo;s preference and convenience. All interviews were audio-recorded. Interviews in Lagos were conducted by OO, in Oyo by KOA and OB, and in Jigawa were conducted by JS and RS, JS, RS and OB are research nurses with experience in qualitative interview techniques, OO has a bachelor\u0026rsquo;s degree with experience in qualitative interview techniques and KOA is a female researcher with a master\u0026rsquo;s degree and experience in qualitative research. They are all fluent in English language and local dialects (Hausa and Yoruba). The interviewers had no personal relationship with the participants. We did not conduct repeat interviews. Transport fare/inconvenience fare was given as incentive to all participants.\u003c/p\u003e \u003cp\u003eAn in-depth interview guide was used to explore perception, motivation, barriers influence choice of place of antenatal care and delivery services. (see Appendix 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe analysis team included KOA, OE, RQ and AAB. KOA and JS independently reviewed transcripts for completeness and accuracy. An inductive thematic analysis was conducted utilising the Braun and Clarke reflexive thematic analysis approach (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The first step was data familiarisation, then OE, RQ and KOA blindly coded the data and generated descriptive codes in the first round. Codes were then categorised, and the team collaboratively reviewed categories and created themes. The theme generation process was iterative, involving several rounds of discussion and refining among the entire team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e Prior to interviewing and recording participants, we obtained verbal and written informed consent ensuring anonymity and confidentiality. Participants were allowed to withdraw at any time and were informed that the interviews were for research purposes. All data is being stored at Oxygen for Life Initiative according to data management regulations. We received approval from Jigawa state Ministry of Health (ref: JGHREC/2023/152), Lagos state University Teaching hospital (ref: NHREC04/04/2008) and UI/UCH ethics committee (ref: UI/EC/22/0311).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified four major themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) preference for safe, comfortable and quality health services; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Social diffusion and cultural/religious influences; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Physical, geographical and financial inaccessibility; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Symbolic perception of health facilities; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Misunderstanding of health promoting and preventive care in pregnancy.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePreference for safe, comfortable and quality health services\u003c/h2\u003e \u003cp\u003eParticipants emphasised their preference for safe, comfortable, and high-quality healthcare services as key considerations influencing their choice of delivery location. In Oyo State, nursing mothers expressed concerns regarding the proficiency of healthcare workers (HCWs) and the apparent shortage of experienced personnel, particularly in PHCs. This shortage raised doubt about the competence of HCWs in PHCs to provide maternal health services, including the management of pregnancy-related complications, and scepticism about the quality of care available. This directly impacted trust in PHCs, prompting a preference for childbirth in secondary and tertiary health facilities. Similar sentiments were shared by nursing mothers in Lagos, who consistently expressed a preference for general hospitals and tertiary hospitals with readily available medical staff. This preference was largely driven by the perception that these hospitals possess the expertise necessary to handle potential childbirth complications. The presence of doctors, in particular, was cited as a crucial factor, instilling reassurance and confidence in women about the quality of care they would receive.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI went to the PHC close to my workplace, but their capacity cannot deliver the baby\u003c/em\u003e (Nursing mother 05 OYO)\u003c/p\u003e\u003cp\u003e \u003cem\u003eThey (government hospitals) have good hands, they have qualified hands (specialist in every area) that can attend to people\u003c/em\u003e (Nursing mother 01 LAGOS)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, several nursing mothers expressed concerns regarding the pathway to care in secondary and tertiary level facilities, particularly the long waiting times and bureaucratic processes encountered during service utilisation. As expressed by one these challenges deter women from selecting facilities for childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe hectic protocol of Adeoyo (SHF), where you will have to be going from one place to the other. I ran away from the stress that they gave us there\u003c/em\u003e (Nursing mother 03 OYO)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePoor infrastructure and limited medical supplies were challenges repeatedly mentioned by nursing mothers and healthcare workers as influencing the choice of place of delivery. In Oyo and Jigawa, nursing mothers and HCWs raised concerns regarding the lack of 24-hour services in PHCs, with a gap in access to care during nighttime hours. This lack of round-the-clock services raised significant apprehensions among nursing mothers while they were pregnant, as they recognized the unpredictable nature of pregnancy journeys. With the possibility of going into labour at any time, the absence of nighttime services in primary healthcare centres presented a potential barrier to accessing timely and necessary care during childbirth. In Jigawa, nursing mothers added the lack of toilet facilities as a major factor they consider while choosing a place for delivery. This finding shed light on the practical concerns of hygiene and comfort that women weigh in when making such a critical decision.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSome women don\u0026rsquo;t come to give birth in the PHCs because of privacy, we don't have toilets for ANC clients and you know most pregnant women do urinate a lot and would be going to that outside toilet like 3 to 4 times before they go home and their toilet is not clean. Some women urinate outside. One also told me that people do get infected with different diseases because they used our toilet\u003c/em\u003e (HCW 01 JIGAWA)\u003c/p\u003e \u003cp\u003e \u003cem\u003eI went to a PHC to enquire, and they said they don\u0026rsquo;t do night (provide 24 hours services). So, I had to look for another place\u003c/em\u003e (Nursing mother 04 OYO)\u003c/p\u003e \u003cp\u003eThe poor attitude of HCWs in government owned/formal health facilities was an issue repeatedly highlighted by nursing mothers in Oyo and Jigawa. Nursing mothers reported discouraging interactions and disrespectful attitudes from HCWs during antenatal care visits, which subsequently deterred them from opting for facility-based childbirth at government facilities, and to some choosing private hospitals. Specifically, they valued the respectful treatment and attentive care provided by healthcare workers in private hospitals and expressed a preference for these facilities. This positive experience motivated their trust in private facility-based childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhen I went to deliver at the general hospital, I was there for over an hour without being attended to. I was crying in pain and begging them to attend to me, then she (the health worker) came with anger and poured insults on me but in the private hospital, the doctor and the nurse were all on my head till I delivered, and they were petting me and talking to me so calmly. I like the way the private hospital treats me, and I like the way they allow my husband to enter into the labour room with me. I prefer to deliver at a private hospital\u003c/em\u003e (Nursing mother 03 JIGAWA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSocial diffusion and cultural/religious influences\u003c/h2\u003e \u003cp\u003eIn Oyo, we found significant social dynamics influencing decision-making with birth experiences shared by other mothers\u0026rsquo; a key consideration. Nursing mothers who had previous live delivery experiences at non health facility-based settings (TBAs, mission homes) recounted positive experiences associated with home and community births, citing factors such as safe childbirth, familial support and privacy that come with the birthing process. This was re-enforced by the diffusion of information within their social circles with stories of successful home births within their community encouraging them to choose the same path. Additionally, cultural and religious influences surrounding childbirth, coupled with longstanding traditions of relying on TBAs for delivery assistance, further influenced women's decision to deliver at home.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eMy pastor\u0026rsquo;s wife had her 1st born and second born here (TBA). She didn\u0026rsquo;t say anything bad about this place. She said they attended to her very well that when she\u0026rsquo;s pregnant again there\u0026rsquo;s nobody that will tell her before she comes back, she was even the one that gave me courage to come here\u003c/em\u003e (Nursing mother 01 OYO)\u003c/p\u003e\u003cp\u003eNursing mothers in the three states frequently highlighted spousal support in decision-making processes for where they would give birth. Specifically, joint decision-making within the family was reported to favour different locations in all states - births at mission homes or traditional birth homes and residential home. They emphasised that the decision of where to deliver was not solely made by the individual woman but rather involved input and consensus from the husband.\u003c/p\u003e\u003cp\u003e \u003cem\u003eI wanted a private hospital. My husband approved of me going to a private hospital, but I also talked about it with his uncle too, who said he doesn\u0026rsquo;t want us to go to a private hospital. Although his nephew (my husband) wanted a private hospital, he(uncle) was not in support of us going to a private hospital. When I was pregnant, he told us not to go early for antenatal until he later approved of private hospital\u003c/em\u003e (Nursing mother 03 OYO)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn Jigawa, personal comfort and cultural norms influenced women's preferences for the gender of healthcare providers during childbirth. Their husbands generally were against male HCWs providing services to their wives and the older women were not comfortable with being attended to or treated by younger female HCWs as this was perceived to be a threat to their self-esteem.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSome (husbands) don't allow their wives to come to the hospital because there are no female doctors here\u003c/em\u003e. Also, s\u003cem\u003eome women said because the nurses in the ANC unit are younger nurses. That some of the nurses are even more like their grandchildren so they don't want \u0026ldquo;small children of yesterday\u0026rdquo; to come and be palpate them and see their nakedness\u003c/em\u003e (HCW 01 JIGAWA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePhysical, geographical and financial inaccessibility\u003c/h2\u003e \u003cp\u003eNursing mothers and healthcare workers in Lagos and Oyo repeatedly mentioned limited transportation options as challenges for women residing far from healthcare facilities. This lack of accessible transportation options was said to present a considerable obstacle for these women, as it hindered their ability to reach healthcare facilities in a timely manner when in labour. Consequently, many women felt compelled to resort to home delivery or sought assistance from community birth attendants or mission homes for childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eShe (pregnant woman) said, yesternight when she was falling to labour, the husband was not around, and there was no means of transportation to reach here (PHC facility), and nobody was ready to take her here\u003c/em\u003e (HCW 02 OYO)\u003c/p\u003e\u003cp\u003e \u003cem\u003eWhen it rains, it is very crazy on this road and makes it very difficult to transport myself to the health facility\u003c/em\u003e (Nursing mother 01 LAGOS)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAmong nursing mothers in Lagos, Oyo and Jigawa states, distance from formal health facilities emerged as a prominent factor motivating them to opt for home deliveries and other non-facility deliveries. This was particularly pronounced in rural areas where healthcare facilities were often situated far from communities. The perceived convenience and accessibility of TBAs within close proximity to their homes played a pivotal role in shaping women's preferences for home births.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe distance from the home is far far from healthcare facilities which the reason I make use of this place (TBA\u0026rsquo;s) is because it\u0026rsquo;s closer to my house.\u003c/em\u003e (Nursing home 02 LAGOS)\u003c/p\u003e\u003cp\u003eEconomic factors such as financial constraints influenced decisions on choice of place of delivery as well, with some women opting for home births, delivery at mission homes as the cost of formal healthcare was too high. HCWs and nursing mothers in three states confirmed this factors, but there was also a notable mention of nursing mothers seeking the assistance of community or traditional birth attendants, not only for financial reasons but also due to the empathy and understanding they offered.\u003c/p\u003e\u003cp\u003e \u003cem\u003eSome women don't have the money for a bike to go to the hospital. In such a situation it is only when the women are having challenges with the pregnancy, they would think of accessing any facility that is most close to them if not those women that are ok, they won't go anywhere\u003c/em\u003e (HCW 01 JIGAWA)\u003c/p\u003e\u003cp\u003e \u003cem\u003eI chose to deliver with the help of a traditional birth attendant not just because it was more affordable, but also because they truly understand and care for us in ways that made me feel supported and respected\u003c/em\u003e (Nursing mother 01 OYO)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSymbolic perception of health facilities\u003c/h2\u003e \u003cp\u003eIn Jigawa, participants expressed the prevailing cultural belief that home delivery signifies in their words, \u0026ldquo;show of strength\u0026rdquo; which fostered hesitation towards facility delivery. Also, healthcare facilities are predominantly perceived as a recourse for managing complications during childbirth, rather than as a primary option for delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eOur culture demands women to show her strength by giving birth alone at home without going to the hospital. Some women because of this culture they would manage their labour alone and deliver alone in their room. It is when she pushes her baby out before she will call for help, especially multigravida\u003c/em\u003e (HCW 03 JIGAWA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, nursing mothers in both Lagos and Oyo states voiced significant concerns regarding fear of caesarean section as a deterrent to secondary facility-based childbirth. Specifically, they expressed apprehension about medical procedures and potential adverse outcomes during childbirth which deeply influenced their decision-making process, leading some women to opt against secondary facility-based childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI used to be fearful of general hospital because I think that everybody that goes to general hospital must undergo a surgical procedure\u003c/em\u003e (Nursing mother 02 LAGOS)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLack of awareness about the benefits of hospital births and ignorance about the possible complications that may arise from delivery at a non-health facility-based institution clearly influenced decision-making among some nursing mothers in Jigawa state. Our results revealed a general lack of understanding among nursing mothers about the potential risks and complications that could arise during childbirth outside of a healthcare facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eHonestly, I don\u0026rsquo;t think they do tell us about the dangers of not giving birth in the hospital, except if they do say it but I wasn\u0026rsquo;t there. They don\u0026rsquo;t even tell us to come to the hospital and even if they do tell others, I don\u0026rsquo;t know but they did not say I should come back to give birth to the best of my knowledge\u003c/em\u003e (Nursing mother 01 JIGAWA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMisunderstanding of health promoting and preventive care in pregnancy\u003c/h2\u003e \u003cp\u003eHCWs highlighted the misinformation around haematinics (drugs that improve blood quality or quantity by increasing haemoglobin levels and red blood cell count such as folic acid) being issued at the facility during ANC that women in Jigawa believe can increase the size of their babies. This makes them avoid health facilities for ANC antenatal care. Similarly, in Oyo nutrition during pregnancy is believed to promote macrosomia (a condition where a newborn has an excessive birth weight) which may lead to caesarean section.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSome women don't want to come for ANC because they believe that iron supplements and folic acid are making babies to be big inutero. So they won't come so that they won't be given the drugs\u003c/em\u003e (HCW 01 JIGAWA)\u003c/p\u003e\u003cp\u003e \u003cem\u003eWe observed that some wombs are large as they (women) eat. You know what we eat is what the baby eats as well in the womb. The way the baby sees the food is the way the baby eats it. Therefore, it will increase the weight of the baby, so we would tell them when you want to eat, take liquid food like pap and drink a lot of water\u003c/em\u003e (TBA 02 OYO)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study sought to understand the experiences and perceptions that influence women\u0026rsquo;s choice of where they access maternal health services in Lagos, Oyo and Jigawa. We found motivations for choice of place delivery are complex and contextual. Infrastructural deficits and limited HCW capacity deter women from utilising PHCs, while bureaucratic processes were barriers to service utilisation in secondary hospitals. In Jigawa, delivery at home is regarded as a show of strength and hospital delivery is culturally unusual, while misconceptions about nutrition in pregnancy were also described as preventing uptake of ANC services.\u003c/p\u003e \u003cp\u003eConsistent with prior qualitative research in Nigeria (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) our study reveals widespread concerns among women regarding the expertise and availability of healthcare workers in PHCs. The perceived shortage of skilled personnel and poor infrastructure in PHCs significantly undermines women's confidence in these facilities for childbirth, leading them to prefer higher-level institutions perceived to offer better quality care. Our findings indicate that pregnant women prefer to choose a trusted and dependable facility for planned delivery which can accommodate their needs reliably at any time of day, facilities where 24-hour services are being offered and not affected by strikes. Investment in healthcare workforce, infrastructure improvement and robust monitoring are recommended to enhance women's confidence in utilising primary healthcare centres for childbirth in Nigeria (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWHO recommends a global target of at least 90% of all births being attended by a skilled birth attendant (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Although the SDG indicator 3.1.2 - Proportion of births attended by skilled health personnel does not have an explicit SDG target. The SDG global target says, it is expected that it reaches a \u0026lsquo;universal\u0026rsquo; coverage level, meaning that every woman gets this support at the time of birth (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Despite the efforts Nigerian has put in place, more effort is needed to achieve this. Efforts towards implementing the 2024 Nigeria health sector renewal investment initiative on comprehensive revamp of physical infrastructure, equipment and retraining of frontline health workers and Basic Health Care Provision Fund (BHCPF) redesigned to enhance access to essential healthcare services as outlined in the National Health Act (2014) should include women and communities perspectives to promote their uptake of maternal health services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to the lack of night shifts influencing women's maternal healthcare decisions, our study underscores the persistent infrastructural deficit in PHC facilities in Nigeria. Despite government initiatives aimed at revamping PHCs, such as the National Primary Health Care Development Agency (NPHCDA) revitalization program, our findings suggest that these efforts have not yielded tangible and sustained improvements in healthcare accessibility and quality at the grassroots level (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This highlights a critical gap in translating policy initiatives into impactful outcomes on the ground. The continued infrastructural challenges, including inadequate facilities, equipment, and staffing, significantly hinder the provision of essential maternal healthcare services at the primary care level. Therefore, alongside addressing financial barriers, urgent attention is needed to strengthen PHC infrastructure and ensure sustained support for revitalization initiatives to effectively enhance maternal health services and outcomes in Nigeria.\u003c/p\u003e \u003cp\u003eThe challenges women faced within healthcare settings, such as long waiting times, bureaucratic processes, and inadequate infrastructure, resonate with other studies which reported barriers to accessing maternal healthcare services (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This highlights that pregnant women place significant importance on factors like comfort and a stress-free environment with hygiene and sanitary facilities, when selecting a location for receiving antenatal care and delivering their babies. While these factors deter women from seeking facility-based childbirth, they also highlight systemic deficiencies that need to be addressed through targeted healthcare system improvements in Nigeria (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimilarly, the negative experiences reported by nursing mothers in our study, including disrespectful attitudes from healthcare workers in government-owned facilities, corroborate findings from previous research (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This underscores the critical role of patient-provider interactions and the impact of healthcare worker attitudes on women's healthcare-seeking behaviour. Our study showed that provider-patient relationships and the quality of interpersonal care emerge as critical determinants influencing women's choices of healthcare facilities for childbirth. This requires a systemic solution including review of preservice training. Anecdotal evidence suggests HCWs are subjected to abusive treatment during pre-service training, an unfriendly training environment which might have shaped their perception about client relationships (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Therefore, efforts towards improving healthcare worker training and fostering a culture of respectful and empathetic care are essential steps towards enhancing women's trust in utilising health facility-based maternity services (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the influence of social dynamics, cultural norms, economic constraints, and limited transportation options on women's childbirth decisions is consistent with findings from other studies in Nigeria (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Financial considerations are a crucial factor that often dictate women's decisions regarding healthcare utilisation, highlighting the need for targeted interventions to address economic disparities and enhance accessibility to maternal healthcare services (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Cultural factors such as community norms surrounding childbirth, has been revealed as an influential determinant shaping women's preferences for home births or facility-based care. It showed that the desire of women particularly in the northern part of Nigeria to be perceived as strong women within their community emerged as a dominant influence on their decision-making. This is similar to the findings from a study in Africa reporting that home birth makes a real woman (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). This cultural value appeared to outweigh considerations of the risks associated with home delivery versus the benefits and safety offered by facility-based deliveries (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Community engagement and culturally sensitive healthcare approaches are essential for addressing these factors and promoting appropriate maternal healthcare seeking and utilisation behaviours (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe symbolic perception of health facilities and false beliefs about nutritional supplements among pregnant women in Jigawa present complex challenges for maternal healthcare utilisation and preventive care. The observation that misinformation, particularly regarding supplement use during pregnancy, significantly influences women's decisions to avoid hospital births reflects a critical barrier to accessing essential maternal health services (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). The false belief that taking supplements could reduce foetal size highlights a fundamental misunderstanding of prenatal nutrition and its impact on foetal development. This misconception likely stems from broader symbolic perceptions of health facilities and healthcare practices, contributing to a disconnect between health-promoting behaviours and preventive care (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Furthermore, the assumption that nutrition causes intrauterine growth restriction, anaemia, and increased negative outcomes underscores the urgent need for targeted education and interventions to dispel myths and promote evidence-based practices. Addressing these misconceptions requires a multi-faceted approach that engages healthcare workers, community leaders, and traditional birth attendants to deliver accurate information and culturally sensitive maternal health education (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). By challenging false beliefs and enhancing trust in healthcare services, we can empower pregnant women in Nigeria to make informed decisions that optimise maternal and foetal health outcomes (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eOne of the limitations in this study is that nursing mothers may have felt compelled to provide responses they believed were expected or viewed favorably, particularly when interviews were conducted within healthcare facilities. This bias could have led some women to express more positive opinions about the facilities than they genuinely felt. To minimize this, we conducted the interviews in a private place and assured participants that interview is confidential.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe found women\u0026rsquo;s choice of place of delivery is influenced by a complex interplay of factors. Prominent among these are health system inadequacies, socio-economic influences, and the desire for comfortable and quality maternal healthcare. Healthcare providers, TBAs, and nursing mothers highlighted these factors as critical in shaping their decisions regarding where to give birth. The implications of these findings call for multifaceted interventions at the policy, healthcare delivery, community engagement, and individual levels to overcome the barriers and promote safer, more comfortable, and accessible maternal healthcare services. By addressing these challenges, healthcare systems can work towards achieving better maternal health outcomes and ensuring that women have the support and resources needed to make informed decisions about childbirth location based on their preferences and needs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets\u0026nbsp;used and/or analysed during the current study are not publicly available due to privacy restrictions of the participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project is a self-funded project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAAB, KOA, and AGF conceived and designed the study. KOA, OB, OO, JS and RS were involved in data collection with oversight from AAB and AGF. \u0026nbsp;KOA, OE, RQ, JS and AAB analysed the data. KOA and AAB drafted the manuscript with inputs from CK and AGF. All authors read and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWe thank the data collectors, and study participants for their time and support.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAjegbile ML. Closing the gap in maternal health access and quality through targeted investments in low-resource settings. 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Defining competent maternal and newborn health professionals. 2018. 1\u0026ndash;42 p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations Children\u0026rsquo;s Fund. DELIVERING FOR WOMEN: Improving maternal health. 2022;3\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAigbiremolen AO, Alenoghena I, Eboreime E, Abejegah C. Primary Health Care in Nigeria: From Conceptualization to Implementation. 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BMC Pregnancy Childbirth [Internet]. 2023;23(1):1\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12884-023-06118-y\u003c/span\u003e\u003cspan address=\"10.1186/s12884-023-06118-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrpin J, Puthussery S, Davidson R, Burden B. Women\u0026rsquo;s experiences of disrespect and abuse in maternity care facilities in BenueState, Nigeria. BMC Pregnancy Childbirth. 2018;18(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. Health facility delivery in sub-Saharan Africa: Successes, challenges, and implications for the 2030 development agenda. BMC Public Health. 2018;18(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFukkink R, Helmerhorst K, Gevers Deynoot-Schaub M, Sluiter R. Training Interaction Skills of Pre-service ECEC Teachers: Moving from in-Service to Pre-service Professional Development. Early Child Educ J [Internet]. 2019;47(4):497\u0026ndash;507. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1007/s10643-019-00928-6\u003c/span\u003e\u003cspan address=\"10.1007/s10643-019-00928-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmar N, Quaife M, Exley J, Shuaibu A, Hill Z, Marchant T. Toward improving respectful maternity care: A discrete choice experiment with rural women in northeast Nigeria. BMJ Glob Heal. 2020;5(3):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhayimana A, Kearns I. Healthcare Providers \u0026rsquo; Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers. in Five Hosp Rwanda. 2024;1\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: Evidence from a population-based survey. Reprod Health. 2015;12(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhuru RR. Maternal Care Utilization in Primary Healthcare Centers in Nigerian Communities. Community Heal Equity Res Policy. 2022;42(3):325\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlonade O, Olawande TI, Alabi OJ, Imhonopi D. Maternal mortality and maternal health care in Nigeria: Implications for socio-economic development. Open Access Maced J Med Sci. 2019;7(5):849\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahlberg M, S\u0026ouml;derg\u0026aring;rd B, Thorson A, Alfv\u0026eacute;n T, Awiti-Ujiji O. Being perceived as \u0026lsquo;a real woman\u0026rsquo; or following one\u0026rsquo;s own convictions: a qualitative study to understand individual, family, and community influences on the place of childbirth in Busia, Kenya. Cult Heal Sex. 2015;17(3):326\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOwigho O, Isara A. Women\u0026rsquo;s perception of quality and utilization of antenatal care and delivery services in Oshimili South Local Government Area of Delta State, Nigeria. J Community Med Prim Heal Care. 2022;34(1):81\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub-Saharan Africa: Evidence from nationally representative health facility assessments. J Glob Health. 2017;7(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUdenigwe O, Okonofua FE, Ntoimo LFC, Imongan W, Igboin B, Yaya S. Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria. BMC Pregnancy Childbirth. 2021;21(1):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalmanu RA, Odetola TD. A community-based intervention study for enhancing Hausa women\u0026rsquo;s knowledge about maternal healthcare services. 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Available from: www.icmje.org/coi_disclo-.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleary SA, Ettienne-Gittens R, Heffer RW. Perceptions of Preventive Health Care and Healthy Lifestyle Choices for Low Income Families: A Qualitative Study. ISRN Prev Med. 2013;2013:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdatara P, Afaya A, Baku EA, Salia SM, Asempah A. Perspective of Traditional Birth Attendants on Their Experiences and Roles in Maternal Health Care in Rural Areas of Northern Ghana. Int J Reprod Med. 2018;2018:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller T, Smith H. Establishing partnership with traditional birth attendants for improved maternal and newborn health: A review of factors influencing implementation. BMC Pregnancy Childbirth. 2017;17(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmutah-Onukagha PD, Rodriguez MPHN, Opara MPHM, Gardner MPHMSWI, Assan MPHM, Hammond BSMA. Progresses and Challenges of Utilizing Traditional Birth Attendants in Maternal and Child Health in Nigeria. Int J Matern Child Heal AIDS. 2018;6(2):130\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal health services, place of delivery, nursing mothers, healthcare workers, traditional birth attendants","lastPublishedDoi":"10.21203/rs.3.rs-4931243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4931243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMaternal health remains a significant public health concern globally, particularly in low- and middle-income countries such as Nigeria. Despite concerted efforts to improve maternal health services to achieve the Sustainable Development Goal of less than 70 maternal deaths per 100,000 live births by 2030, maternal mortality rates in Nigeria remain unacceptably high. Understanding the factors that shape women's choices in selecting the place of delivery could help tailor services and improve quality of care for mothers and infants. Therefore, our study seeks to understand the experiences, barriers and facilitators influencing where women choose to access maternal health services in three diverse Nigerian states: Lagos, Oyo and Jigawa.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study using in-depth interviews with nursing mothers, healthcare workers in Lagos, Oyo and Jigawa states, and traditional birth attendants (TBAs) in Lagos and Oyo. We used maximum variation sampling to purposefully recruit nursing mothers in their puerperium who delivered in different places. Healthcare workers and TBAs were purposively selected from birth health facilities and birth homes. We used reflexive thematic analysis to generate themes across participant types and states.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified five major themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) preference for safe, comfortable and quality health services; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Social diffusion and cultural/religious influences; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Physical, geographical and financial inaccessibility; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Symbolic perception of health facilities and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Misunderstanding of health promoting and preventive care in pregnancy. The main reasons for choice of place of delivery were 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\u0026rsquo;s homes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe found women\u0026rsquo;s choice of place of delivery is influenced by a complex interplay of factors. Prominent among these are health system inadequacies, socio-economic influences, and the desire for comfortable and quality maternal healthcare. Healthcare providers, TBAs, and nursing mothers emphasised these determinants as critical in shaping their 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.\u003c/p\u003e","manuscriptTitle":"“I went to the primary health centre close to my workplace, but their capacity cannot deliver the baby”: Understanding factors influencing choice of providers for maternal health services in Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 22:53:34","doi":"10.21203/rs.3.rs-4931243/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-17T06:36:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-15T21:45:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-15T13:05:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-14T10:14:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-12T12:05:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78768676237646912489477960078173800834","date":"2024-10-05T19:42:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339867186368863837805011946022586677047","date":"2024-10-02T12:40:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148005608931471350589677113190028924124","date":"2024-10-01T22:36:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136871700419844122974095671237379063500","date":"2024-09-07T05:34:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231470068339553537785204793274057840430","date":"2024-09-05T04:36:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-26T16:06:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-21T07:15:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-19T04:32:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-19T04:31:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-08-17T21:41:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87c920eb-9687-4fa2-a7ea-2bc1be40f56d","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T15:59:28+00:00","versionOfRecord":{"articleIdentity":"rs-4931243","link":"https://doi.org/10.1186/s12884-025-07382-w","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-03-25 15:57:10","publishedOnDateReadable":"March 25th, 2025"},"versionCreatedAt":"2024-09-16 22:53:34","video":"","vorDoi":"10.1186/s12884-025-07382-w","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07382-w","workflowStages":[]},"version":"v1","identity":"rs-4931243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4931243","identity":"rs-4931243","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}