An experience-informed qualitative narrative of factors influencing choice of birthplace among suburban women of Calabar Municipality, Nigeria

An experience-informed qualitative narrative of factors influencing choice of birthplace among suburban women of Calabar Municipality, Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An experience-informed qualitative narrative of factors influencing choice of birthplace among suburban women of Calabar Municipality, Nigeria Precious Chidozie Azubuike, Matthew Ejeh Abba, Uchenna Frank Imo, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6382388/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background In many low and middle-income countries, childbirth services are frequently insufficient, unavailable, or prohibitively expensive, leading to poor health outcomes for women and their families. Primary health centers majorly deliver limited childbirth services in Africa, and different factors affect the uptake of these services by women. Our study aimed to investigate the factors influencing the choice of birthplace among the suburban population of Calabar Municipality in Nigeria. Methods This study used a descriptive qualitative design to elicit participants’ opinions and factors influencing the choice of birthplace among pregnant women, traditional birth attendants (TBAs), and healthcare workers (HCWs) in the Calabar Municipality. Participants were selected via convenience sampling followed by a snowball technique. Ten interviews were conducted among TBAs and HCWs, while three focus group sessions were conducted among pregnant women. Data were analyzed using a narrative analysis approach with NVivo v12. Results Seven themes emerged from our findings, representing the influencing factors for choice of birthplace: i) Unpredictability of labor and situational constraints, ii) Preference for personal choice and comfort, iii) PHC accessibility and staff behavior, iv) Financial constraints and cost considerations, v) Importance of prenatal care and health practices, vi) Complications and referral challenges, vii) Cultural practices and community influence. Conclusion Findings from this study highlight that the preference for TBAs was largely due to poor hospitality and care offered by PHC workers. This highlights the importance of fostering empathetic and compassionate care by PHC staff to encourage greater uptake of professional healthcare services. Since the high cost associated with professional healthcare services was a major deterrent, there is an urgent need to address the financial burden through cost reduction, health insurance financing, or subsidizing services, which is essential to enhance maternal and child health outcomes while promoting equitable care to skilled birth care. Traditional birth attendants maternal health qualitative study narrative analysis choice birthplace Introduction Maternal healthcare services are an important element of women's health and include a variety of medical and support services offered throughout pregnancy, delivery, and the postpartum period [ 1 , 2 ]. These services are essential for the health and well-being of both mothers and babies, and they help to reduce maternal and infant mortality rates. Access to appropriate maternal healthcare services is a fundamental human right, yet many women worldwide continue to encounter severe challenges in receiving these critical treatments [ 3 , 4 ]. In many low and middle-income countries, maternal healthcare services are frequently insufficient, unavailable, or prohibitively expensive, leading to poor health outcomes for women and their families [ 5 ]. Major maternal healthcare services include prenatal care, postnatal care, child health, and childbirth services [ 6 ]. Childbirth services in Africa are majorly delivered by primary health centers (PHC), and different factors affect the uptake of these services by women [ 7 , 8 ]. Different studies across several regions in Africa have brought to light some significant factors affecting the choice of birthplace among pregnant women [ 9 – 12 ]. A study in western Ethiopia revealed that personal factors such as maternal age and level of education were significant influencers of choice of birthplace among the respondents [ 11 ]. Societal factors were also seen to be of some consequence, and these include the infrastructural state of PHCs, proximity to health facilities, availability of health facilities, poor referral system, and the wealth of available skilled attendants [ 11 ]. A corresponding study conducted in Ghana revealed that statistically significant variables as regards choice of birthplace among women included level of education, manner of treatment of pregnant women by hospital staff during labor, experience with previous childbirths, and accessibility of antenatal care [ 10 ]. Another study in Uganda revealed choices influencing birthplace among the respondents ranged from personal factors such as financial dependency to community factors such as societal perceptions towards natural birth methods [ 9 ]. However, another study in Sierra Leone shows a little nuance from the studies highlighted above, revealing that knowledge levels of intimate partner violence (IPV) were the major influencing factor of choice of birthplace among women [ 12 ]. Other influences were cited in that study, including proximity to health facilities and the number of antenatal care visits [ 12 ]. Several studies in Nigeria have analyzed influencing factors for choice of birthplace [ 7 , 13 , 14 ]. For instance, a study in the South-Eastern revealed that pre-planning to deliver at a hospital, occurrence of labor at night, and inconvenience of labor in allowing time for transportation were significant determinants of child delivery location [ 7 ]. A similar study in Ebonyi state highlighted the attitude of PHC workers, cost of health services, number of antenatal visits, and labor complications as some determinant factors of choice of delivery location among the respondents [ 14 ]. These findings, which are similar to those of the studies in other regions of Africa, suggest a similitude of experiences in Nigeria and other African countries [ 15 – 19 ]. This study looks to add information to the already existing body of knowledge by considering factors influencing the choice of birthplace among pregnant suburban women of Calabar municipality, specifically in Nigeria. This is intended to identify further nuances and underlying influences of choice of birthplace, providing a springboard for deeper exploration of this topic. Methods Study design, population, and sample This study used a descriptive qualitative design to elicit participants’ opinions and factors influencing their choice of childbirth place among pregnant women. This approach allows for the expression of ideas and experiences that may otherwise be unaccounted for in structured interviews. The researchers utilized the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide the description and reporting of this study [20]. The nature of this study focused on understanding the different viewpoints and in-depth information of pregnant women, traditional birth attendants (TBAs), and healthcare workers (HCWs) regarding the influencers of childbirth location and care. The target population included pregnant women and TBAs in the community and the HCWs within the selected primary healthcare centres (PHCs). The study was conducted in Calabar Municipality, which doubled as the state capital and a local government area (LGA) in Cross River State, Nigeria. The study setting was chosen because of the existing longstanding relationship between the study team and the participants. Christianity, followed by Islam, is the widely practised religion in the LGA. Trading, industrial activities, and civil service occupations are the key economic activities in the Calabar Municipal [21]. Popular opinion has it that most pregnant mothers in this LGA utilize TBA compared to modern healthcare during childbirth because of their beliefs, low cost, and other perceptions. Women of reproductive age in the communities were approached with the support of local researchers dwelling in the study location, following the approval from the community leaders in Calabar Municipal. The objectives and structure of the study were explained in Efik, Qua, and Pidgin English (which are the common languages spoken in the area). Those who voluntarily consented to participate were subsequently recruited using a convenience sampling technique, followed by a snowballing sampling approach over two months. In parallel, as TBAs appear to be the closest personnel for childbirth in the communities, it was essential to recruit them to grasp the factors influencing pregnant women’s choice of childbirth from their perspectives. Also, HCWs, as the main professionals responsible for quality childbirth, treatment response, and clinical intervention, were recruited in the study. As skilled birth attendants, their perspectives were crucial in understanding the factors influencing the choice of childbirth location. Key Informant interviews (KII) were conducted among TBAs and HCWs, while the focus group discussion (FGDs) was conducted for pregnant women. Ten interviews were conducted among TBAs and HCWs, while three FGD sessions were conducted among pregnant women. Data collection procedure The data collection was conducted using pre-designed KII and FGDs guides. The guides were adapted from existing literature [22,23] with the support of subject experts. Following the development of the guides, a pre-test exercise was conducted among a subset of the participants in a different location. Feedback from the exercise, which included rewording of questions and the removal of double-barreled questions, was incorporated into the guides. Some examples of the questions in the guides include: “What influences the choices that you make about where to deliver?”, “What factors may keep you from delivering at your first choice?”, “Imagine yourself ready to give birth, what is your first choice of where you will deliver the baby?”. Before data collection, the research team provided a detailed information sheet outlining the purpose and procedures of the study. After addressing any questions and concerns, informed consent was obtained from all participants (i.e., pregnant women, TBAs, and HCWs) through signed consent forms. Following this, the participants were asked to choose their preferred time and location for the face-to-face interviews and focus group. In line with the recommendations by Fusch and Ness (2015), data were collected by experienced qualitative researchers, including public health and social science experts, until the saturation was reached or the point at which the information collected was enough for answering the research questions [24]. The data were collected in Efik and Pidgin English, and each session began with some icebreakers to stimulate conversation, and each participant was encouraged to share their insights freely. When participants expressed hesitation or concerns about a particular question, the researcher adjusted the approach by rephrasing the questions, explaining further, or moving to other questions. Each of the KII lasted between 20- 30 minutes, while the FGDs spanned between 30-50 minutes. The data were audio-recorded for analysis. The research employed a reflexive approach to data collection by organizing a debriefing session at the end of each data collection to examine the challenges and address any concerns before subsequent KII and FGD sessions. No repeated interviews or follow-ups were conducted. Data analysis and reporting The recorded data were transcribed into English by local researchers with support from the research team. Appropriate translation and back-translation were done by the research team to ensure that the context closely reflects the insights from the participants. An inductive (bottom-up) and deductive (top-down) approach was used to code the data according to previous guidelines [25,26]. Before analysis, two independent researchers read and familiarized themselves with the transcripts while generating the initial codes. Discrepancies or conflicts arising from the coding exercise were discussed until a consensus was reached. Thereafter, the transcripts were imported to NVivo v12 for indexing and analysis. We leveraged a narrative and storytelling analysis approach to report findings from this study. Narrative analysis serves as a vehicle through which stories are documented in a clear sequential order by giving meanings to experiences [27]. Furthermore, narratives aim to evoke complex events or experiences coherently while revealing the underlying ontology that participants or storytellers communicate [28,29]. The researchers took a neutral position while allowing the true narration of each participant’s quote to fit into each code category. The categories were developed by the entire research team for alignment, and the code groups were compared and refined iteratively to develop final themes. Trustworthiness The researchers engaged in open dialogue throughout all stages of the study, especially during data analysis. Given that most of the researchers are experienced in qualitative studies among pregnant women and maternal and child health-related topics, several discussions were held with qualitative experts while generating the codes and code groups. We ensured that the coded insights were cross-checked with the participants to ensure that their insights were accurately captured. Furthermore, direct quotes from the data were captured in reporting the data to enhance the transferability of the insights from participants. Results Seven themes emerged from our findings representing the influencing factors for choice of birthplace: i) Unpredictability of labor and situational constraints, ii) Preference for personal choice and comfort, iii) PHC accessibility and staff behavior, iv) Financial constraints and cost considerations, v) Importance of prenatal care and health practices, vi) Complications and referral challenges, vii) Cultural practices and community influence. Unpredictability of labor and situational constraints Respondents usually described how the unpredictable nature of work, coupled with circumstances such as timing and transport, disrupted their choice to deliver at the place of their preference, often pushing them to turn to substitutes such as Traditional Birth Attendants (TBAs) or even in unexpected locations. They identified the abrupt nature of labour onset as a determining factor, how it could overpower intentions to reach a hospital, and how distance to Primary Health Care (PHC) facilities was often hampered by operating constraints, i.e., restricted hours, that were incompatible with the unforeseen timing of labour. "Like I said before, I think it is the situation. The situation is that the labour just happens. And they cannot get to decide. You have heard about people who give birth inside the taxi. While going to the hospital. I think they might want to go to the hospital. And the situation is not conducive." (Speaker 5, FGD) "So, what happened was I was just going out, and it was so hot, so I was just doing exercise. So, when I got to that health center, the door was locked, and that was 6 pm. So, the next day when I was still walking around, it was around in the morning, and the place was still locked." (Speaker 6, FGD) "Transportation? Somehow, because sometimes the husband might not be there, and it is difficult to even raise transport to the hospital" (Interviewee, HCW 3) Preference for personal choice and comfort Respondents emphasized the role of personal comfort and preference in the decision to deliver at home or with Traditional Birth Attendants (TBAs) rather than Primary Health Care (PHC) centers. Personal preferences, tied to familiarity and the desire for a quiet birthing experience, often outweighed institutional options as women prioritized autonomy and well-being over medically formal settings. The notion of delivering in a familiar and peaceful environment emerged as a key driver for many women, while some further elaborated on the cultural and personal appeal of home births. Satisfaction with TBAs further reinforced choices, as participants appreciated their alignment with personal needs and comfort. "If you are okay with your pregnancy and somebody can attend to you at that time of the pregnancy. You can deliver in your house. Quietly. Peacefully, and so it is a personal choice. Yes." (Speaker 5, FGD) "Because some people see that delivering in the house when you do not have an issue is a very good thing. Some people will stay in the house and deliver on their own." (Speaker 3, FGD) "I'll still say it's Choice. If everything is okay. The services are okay, the environment is okay, the distance is okay and the charges are okay, then, that’s fine." (Speaker 4, FGD) PHC accessibility and staff behavior Respondents reported significant difficulties with Primary Health Care (PHC) facilities, including poor accessibility and poor relations with the staff, which ultimately discouraged them from using these services compared to Traditional Birth Attendants (TBAs). The unpredictability of labor clashed with restricted PHC availability, leaving women feeling unsupported at critical moments. Staff behavior further compounded these accessibility issues, with participants describing encounters marked by impatience and insensitivity. Participants noted a pattern of dissatisfaction rooted in operational barriers and perceived lack of empathy, highlighting how these factors undermined trust in PHC systems and influenced delivery preferences. "So, I was just like, what if I'm in labor in the morning or it happened at night. Yeah, that was where I registered first. So, when I went back, I was just like, no, I don't think that health center is okay for me. Because this labor of a thing, nobody knows it can happen any time." (Speaker 6, FGD) "Those nurses were shouting at me. It was so annoying. Like I was losing my baby. See the way I was bleeding. They told me to be patient and calm down. They started shouting. So, impatience. Impatience. I don't like it." (Response 2, FGD) "I decided to use the ABC facility when I lost my first baby. It was in the hospital. But when all the money that we spent, they did not even show concern. They just said, Madam, be fast. And I was not feeling well. Madam, be fast. Just call your husband." (Speaker 4, FGD) "Some say the nurses used to shout at them too much. Cross-infection, transfer of infection, either the baby." (Interviewee, HCW 1) Financial constraints and cost considerations Participants reported the cost of hospital/PHC delivery and services as the major determinants of their utilization of TBAs or home delivery. Out-of-pocket payment at hospitals was a major disincentive, particularly in the event of emergencies, as the cost of hospital services deterred the participants, given their economic status. In contrast, TBAs were perceived as more accommodating, offering care that aligned with participants’ economic realities. "My challenge is that when you are in the hospital, you don't have patience. In terms of finances, when you get there, If you don’t have money, you might not be admitted immediately" (Speaker 3, FGD) "The money aspect, yeah, is something to consider because I have someone that even went, and the woman was the one taking care of the mother and even buying the child milk. So they don’t charge much because they know women face difficulties ." (Interviewee, HCW 3) "Again, if in your first experience, you were not treated well, maybe the person was harsh on you, maybe the charges, the hygiene condition of the place, and all those things, you were not well taken care of, I don’t think you would like to go back there." (Interviewee, HCW 2) Importance of prenatal care and health practices There was a strong emphasis among participants on the importance of prenatal care and health practices to ensure maternal and fetal well-being. Respondents noted a range of proactive practices, including medical check-ups, medication adherence, nutritional awareness, and hygiene. A key aspect highlighted was the necessity of regular medical engagement and diagnostic testing. Also, nutrition was another prominent focus, with participants advocating for specific dietary practices to support a healthy pregnancy. Additionally, there was a cautious approach to medication use outside professional guidance. "To stay safe. You take your medication, exercise, and go for check-ups. You run your tests. Very important. To know your HIV status, malaria. Because when you test, there are some sicknesses you have." (Speaker 2, FGD) "To stay healthy during pregnancy. Okay. You eat fruit. Most importantly, to eat fruit. Drink enough water. Do not eat [too much] meal and food until the baby is not too fat" (Speaker 1, TBA Centre 2) "We have said it already: come to the facility, take their drugs, hygiene is very important, eat good food, fruits, vegetables, and take their drugs" (Interviewee, HCW 4) "I would advise them to eat a balanced diet and eat fruits. And if they have any challenges, they should not buy drugs outside. They can only buy paracetamol" (Interviewee, HCW 1) Complications and referral challenges Concerns regarding complications of childbirth and challenges of referrals, particularly where deliveries occur with TBAs rather than PHC facilities, were identified. Risks of delayed recognition and management of complications by TBAs were mentioned by participants, contrasting this with the perceived functionality of PHC referral systems, and also remarking on the responsive nature of pursuing higher levels of care. A recurring theme was the comparative advantage of PHCs in promptly addressing complications through referrals, noting that TBAs may attempt initial interventions, potentially delaying critical hospital transfers and increasing the risk of adverse outcomes, such as fetal loss. "Primary Health Center is better than TBA. There are some cases in the Primary Health Center, they will refer you to the hospital immediately. But in TBA, they will have to tell you, okay, wait, let’s give you this first. Let’s do this. And some people, in some cases, you might lose the baby." (Speaker 6, FGD) "When there are complications, that is when they will come. Many of them that register here still go to TBAs on the day of delivery, and many of them want to refer them back when it is out of hand (when TBAs cannot handle them); they now run down here." (Interviewee, HCW 2) "If I cannot deliver by myself, you have a completed issue, you will be referred to the hospital. At times, the midwife is the one to refer you to the hospital" (Interviewee, TBA 2) "The women utilizing our PHC here are safe, but those in TBAs if not checked, will have Complications during childbirth. After delivery, some will have discharge, others will have bleeding, and some will retain the placenta membrane." (Interviewee, HCW 1) Cultural practices and community influence The role of cultural practices and community influence in shaping women’s choices regarding childbirth emerged as an important theme, often favoring Traditional Birth Attendants (TBAs) over institutional healthcare settings. Participants highlighted how traditional beliefs, familial advice, and spiritual practices intertwine to guide delivery preferences, reflecting reliance on community networks and cultural norms. A significant cultural factor identified was the influence of modesty and familial guidance. For some respondents, spiritual practices, community support, and spiritual reassurance also emerged as key influences. "Maybe some might be among friends, they might say no need to go out to doctor to go and see your nakedness, it’s only for your husband. Some, the mother will say, ‘Don’t go, I have somewhere you can deliver safely, even my friend.’ " (Interviewee, HCW 3) "Even when I came back from the hospital, I had to come here. They prayed for me. They said, don’t worry . And also maybe you attend some fasting. Even your child, they have fasting. They pray and fast." (Speaker 4, FGD) "Like my experience, and I always do it when they come I will first tell them register in the hospital before they come to me, even if they come to me I will say you will go the hospital and register should in case, because this life is not a human being own only God." (Interviewee TBA 2) Discussion Findings from our study revealed that unpredictability of labor and situational constraints were among the predictors of choice of birthplace among women. Participants indicated that the uncertainty of labor constitutes a major determinant of the location of child delivery. The occurrence of labor at odd times has made pregnant women eventually deliver at unplanned places [ 31 ]. This could be their place of work, a friend's residence, their homes, or even in vehicles. Participants in the study also indicated that these situational constraints made them opt for TBAs instead of skilled birth attendants (SBAs) at PHCs. This could be because the residential location of the participants (suburbs of Calabar municipality) may be distant from healthcare facilities. Results from the study also showed that financial constraints and cost considerations are another factor fostering the preference of TBAs over PHCs. Generally, professional healthcare services demand higher costs than TBAs, and this is a major reason for increased subscription to traditional birth methods [ 32 , 33 ]. In addition to this, a previous study in Nigeria has shown that TBAs offer better hospitality and care than SBAs, and this doubles down as an advantage for TBA users [ 33 ]. Findings from studies in Kenya were corroborative of results from this study, which show that financial considerations inspired the study respondents to favor TBAs over PHC delivery [ 34 , 35 ]. Allou (2018) also highlights that in Ghana, cost-effectiveness was one of the major drivers of the preference for TBAs over SBAs. These findings suggest that TBAs are a cheaper option in child delivery compared to PHCs [ 36 ]. Participants from this study also indicated that preference for personal comfort is another driver of the preference for TBAs over PHCs concerning child delivery. The focus group discussants reported that they prefer the autonomy, well-being-oriented, and quiet birthing experience of TBAs over the sophisticated and medically formal setting of hospital facilities. This could stem from their experience of poor quality of care from PHC staff. The study respondents indicated that their experiences with PHC staff were marked by impatience, insensitivity, and lack of empathy, and this essentially undermined their trust in PHC staff. Improper quality of care from hospital staff, regardless of their wealth of adequate equipment, can discourage women from seeking professional healthcare [ 37 , 38 ]. Harsh and insensitive treatment can constitute a mental health stressor for women in labour and may jeopardize childbirth outcomes [ 39 ]. To this effect, friendly and hospitable care is a major driver for preference of TBAs over SBAs by African women [ 33 ]. Corresponding studies in Ethiopia showed similar results, as hospitality and good care were drivers of traditional delivery preference among Ethiopian women [ 40 ]. Results from our study also showed that poor accessibility to PHC facilities was another difficulty pregnant women experienced in childbirth. Participants reported that PHC facilities' inaccessibility and unavailability intersected with unpredictable labor occurrences to render pregnant women helpless at critical moments. This suggests that the residence of the participants on the outskirts of the Calabar town is disadvantageous, as it makes them distant from healthcare facilities within the town region. Additionally, this calls for a need to increase the availability of PHC facilities, as participants indicated that the unavailability of healthcare workers was an issue they faced. Upholding cultural practices and community influence was another emergent influencer of birthplace, as shown in the results of this study. Participants highlighted that traditional beliefs, familial advice, and spiritual practices intertwined to guide their delivery preferences. Generally, cultural, religious, and community factors hold a strong sway in informing people's decisions in Africa [ 41 ]. This is because culture and familial trends are held in high regard. To this effect, not following the trends could result in one being treated as an outcast or not regarded as an integral member of the community [ 41 ]. This may be one of the major reasons women residing in African rural localities opt for natural birth methods and not professional healthcare. However, some participants in our study favored PHC over TBAs. These participants indicated that delayed recognition and handling of birth complications were major challenges discouraging them from subscribing to TBAs or home delivery. Given that professional healthcare has more competent equipment and personnel, they are deemed more reliable in handling birth complications than TBAs. This stands as an advantage over traditional delivery services. This assertion is drawn from the fact that in some cases, TBAs are not able to complete a medical procedure they engaged in, leading to more severe complications or even death [ 32 , 42 ]. Additionally, TBAs' deficiency in medical equipment makes them resort to unhygienic practices such use of unsterile equipment, delayed cord cutting, and unsafe disposal of placenta. These contribute to serious risk factors in maternal health. Strengths and limitations of the study The qualitative technique utilized in this study considers the participants' life experiences to provide a profound grasp of their perspectives. Furthermore, by using open-ended questions, the approach of this study allowed for flexibility in data gathering, which stimulated the exploration of novel ideas and the discovery of relevant new topics and hypotheses. Additionally, the small sample size employed in this study provides some cost-effectiveness in enabling the examination. However, because of the small sample size and the fact that this study only employed a qualitative approach, these findings cannot be readily extended to a larger population. Hence, we call on longitudinal studies using multi-method studies to explore this research area. Conclusion Findings from this study highlight the need to upscale the availability and accessibility of PHCs, as limited access emerged as a major barrier to the utilization of professional healthcare services. The preference for TBA over SBA was largely due to poor hospitality and care offered by PHC workers. This highlights the importance of fostering empathetic and compassionate care by PHC staff to encourage greater uptake of professional healthcare services. Additionally, the high costs associated with professional healthcare services were a major deterrent for low utilization. There is an urgent need to address the financial burden through cost reduction, health insurance financing, or subsidizing services is essential to enhance maternal and child health outcomes while promoting equitable care to skilled birth care. Abbreviations COREQ: Consolidated criteria for reporting qualitative research FGD: Focus group discussion HCWs: Healthcare workers KII: Key Informant interviews LGA: Local government area PHC: Primary health centers SBAs: skilled birth attendants TBAs: Traditional birth attendants Declarations Ethical consideration and consent to participate: Our study complied with the 2013 Declaration of Helsinki [30]. Ethical clearance was obtained from the Research and Ethics Committee of the Cross River State Ministry of Health (Approval number: CRSMH/HRP/REC/2024/477). The interview and discussion guides gave no room for the names and specific identities of respondents, and the confidentiality of information provided was assured and maintained throughout the research, data analysis, and presentation of findings. Written consent was obtained from participants before data collection. Any data obtained from participant(s) who revoked consent was destroyed and not used for the analysis. The data were stored and were only accessible to the study team. Consent for publication: Not applicable. Availability of data and materials: All data relevant to the study are included in the article or uploaded as supplementary information. Conflict of interest statement: The authors declare no conflicts of interest. Funding information: The authors received no funding for the study. Authors' contributions : MEA conceptualized the study. MEA, UFI, and PCA collaborated on the study design and ethical approval. MEA, PCA, UFI, CKO, ACU, PNT, GSA, and AON conducted the data collection, while PCA performed the data analysis. MEA, PCA, UFI, CKO, ACU, PNT, GSA, GMP, AON, and TA wrote the initial draft of the manuscript. PCA, UFI, and TA contributed to the critical review and revision of the manuscript. All authors read and approved the final manuscript. Acknowledgments: The authors appreciate all participants in this study. 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Tsegay Y, Gebrehiwot T, Goicolea I, Edin K, Lemma H, Sebastian MS. Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study. Int J Equity Health. 2013 May 14;12(1):30. Zegeye AM, Bitew BD, Koye DN. Prevalence and Determinants of Early Antenatal Care Visit among Pregnant Women Attending Antenatal Care in Debre Berhan Health Institutions, Central Ethiopia. Afr J Reprod Health [Internet]. 2013 Dec 9 [cited 2025 Apr 4];17(4). Available from: https://www.ajol.info/index.php/ajrh/article/view/98386 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 Health Care. 2007 Dec 1;19(6):349–57. Ubugha P, Okpiliya F, Njoku C, Itu PC, Ojoko, Erhabor F. People and Water: Empirics of Calabar Municipality, Cross River State, Nigeria. Int J Res Environ Sci [Internet]. 2017 [cited 2025 Apr 4];3(2). Available from: https://www.arcjournals.org/pdfs/ijres/v3-i2/2.pdf Hinton L, Dumelow C, Rowe R, Hollowell J. Birthplace choices: what are the information needs of women when choosing where to give birth in England? A qualitative study using online and face to face focus groups. BMC Pregnancy Childbirth. 2018 Jan 8;18(1):12. Kawaguchi Y, Sayed AM, Shafi A, Kounnavong S, Pongvongsa T, Lasaphonh A, et al. Factors affecting the choice of delivery place in a rural area in Laos: A qualitative analysis. PLOS ONE. 2021 Aug 2;16(8):e0255193. Fusch P, Ness L. Are We There Yet? Data Saturation in Qualitative Research. Walden Fac Staff Publ [Internet]. 2015 Feb 1;20(9). Available from: https://scholarworks.waldenu.edu/facpubs/455 Graneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse Educ Today. 2017 Sep;56:29–34. Lindgren BM, Lundman B, Graneheim UH. Abstraction and interpretation during the qualitative content analysis process. Int J Nurs Stud. 2020 Aug 1;108:103632. Cortazzi M. Narrative analysis. Lang Teach. 1994 Jul;27(3):157–70. Delamont S, Atkinson P. SAGE Qualitative Research Methods. 2010;1–1616. Josselson R, Hammack PL. Essentials of narrative analysis. Washington, DC, US: American Psychological Association; 2021. viii, 102 p. (Essentials of narrative analysis). World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects | Research, Methods, Statistics | JAMA | JAMA Network [Internet]. 2013 [cited 2024 Dec 9]. Available from: https://jamanetwork.com/journals/jama/fullarticle/1760318 Moshi FV, Lymo G, Gibore NS, Kibusi SM. Prevalence and Factors Associated with Home Childbirth with Unskilled Birth Assistance in Dodoma-Tanzania: A Cross Sectional Study. East Afr Health Res J. 2020;4(1):92–100. Amutah-Onukagha N, Rodriguez M, Opara I, Gardner M, Assan MA, Hammond R, et al. Progresses and challenges of utilizing traditional birth attendants in maternal and child health in Nigeria. Int J MCH AIDS. 2017;6(2):130–8. Ntoimo LFC, Okonofua FE, Ekwo C, Solanke TO, Igboin B, Imongan W, et al. Why women utilize traditional rather than skilled birth attendants for maternity care in rural Nigeria: Implications for policies and programs. Midwifery. 2022 Jan 1;104:103158. Cheptum JJ, Gitonga MM, Mutua EM, Mukui SJ, Ndambuki JM, Koima WJ. Perception about traditional birth attendants by men and women of reproductive age in rural Migori County, Kenya. Int J Afr Nurs Sci. 2017 Jan 1;7:55–61. Jebet J, Gitonga M, Mutua E, Mukui S, Ndambuki J, Koima W. Perception About Traditional Birth Attendants By Men And Women Of Reproductive Age In Rural Migori County, Kenya. Int J Afr Nurs Sci. 2017 Aug 1;7. Allou L. Factors influencing the utilization of TBA services by women in the Tolon district of the northern region of Ghana. Sci Afr. 2018 Nov 1;1:e00010. Lewis C. The impact of interprofessional incivility on medical performance, service and patient care: a systematic review. Future Healthc J. 2023 Mar 1;10(1):69–77. Mumtaz Z, Sivananthajothy P, Bhatti A, Sommer M. “How can we leave the traditions of our Baab Daada ” socio‐cultural structures and values driving menstrual hygiene management challenges in schools in Pakistan. J Adolesc. 2019 Oct;76(1):152–61. Chauhan A, Potdar J. Maternal Mental Health During Pregnancy: A Critical Review. Cureus. 2022 Oct;14(10):e30656. Taye BT, Zerihun MS, Kitaw TM, Demisse TL, Worku SA, Fitie GW, et al. Women’s traditional birth attendant utilization at birth and its associated factors in Angolella Tara, Ethiopia. PloS One. 2022;17(11):e0277504. Appiah R, Raviola G, Weobong B. Balancing Ethics and Culture: A Scoping Review of Ethico-Cultural and Implementation Challenges of the Individual-Based Consent Model in African Research. J Empir Res Hum Res Ethics JERHRE. 2024 Jul;19(3):143–72. Kassie A, Wale A, Girma D, Amsalu H, yechale M. The role of traditional birth attendants and problem of integration with health facilities in remote rural community of West Omo Zone 2021: exploratory qualitative study. BMC Pregnancy Childbirth. 2022 May 20;22(1):425. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 20 May, 2025 Reviewers agreed at journal 06 May, 2025 Reviewers invited by journal 05 May, 2025 Editor invited by journal 09 Apr, 2025 Editor assigned by journal 06 Apr, 2025 Submission checks completed at journal 06 Apr, 2025 First submitted to journal 05 Apr, 2025 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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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6382388","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453133154,"identity":"ff738d02-4702-4ef4-a606-938617455f2b","order_by":0,"name":"Precious Chidozie Azubuike","email":"data:image/png;base64,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","orcid":"","institution":"Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria","correspondingAuthor":true,"prefix":"","firstName":"Precious","middleName":"Chidozie","lastName":"Azubuike","suffix":""},{"id":453133155,"identity":"7acd88d5-62c0-4c83-a28a-995490c05e78","order_by":1,"name":"Matthew Ejeh Abba","email":"","orcid":"","institution":"Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"Ejeh","lastName":"Abba","suffix":""},{"id":453133156,"identity":"0d3c0ee1-eebf-4e8f-b47e-a0cc38876985","order_by":2,"name":"Uchenna Frank Imo","email":"","orcid":"","institution":"Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Uchenna","middleName":"Frank","lastName":"Imo","suffix":""},{"id":453133157,"identity":"c407a823-931c-4d0b-99eb-b270e3b22285","order_by":3,"name":"Temidayo Akinreni","email":"","orcid":"","institution":"Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Germany","correspondingAuthor":false,"prefix":"","firstName":"Temidayo","middleName":"","lastName":"Akinreni","suffix":""},{"id":453133158,"identity":"108a7593-dc87-4f2a-af55-f12b6f6c1d32","order_by":4,"name":"Chimankpam Kingsley Ogbonna","email":"","orcid":"","institution":"Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Chimankpam","middleName":"Kingsley","lastName":"Ogbonna","suffix":""},{"id":453133161,"identity":"5bbf6665-50be-4920-b394-c04239515814","order_by":5,"name":"Amos Chidera Ufere","email":"","orcid":"","institution":"University of Global Health Equity, Butaro, Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Amos","middleName":"Chidera","lastName":"Ufere","suffix":""},{"id":453133163,"identity":"67683507-4ab7-4cfc-8ef3-217d045be378","order_by":6,"name":"Promise Nmesomachi Timothy","email":"","orcid":"","institution":"Department of Human Anatomy, University of Uyo, Uyo, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Promise","middleName":"Nmesomachi","lastName":"Timothy","suffix":""},{"id":453133166,"identity":"cefaf353-50cf-4d55-8d29-5d9dfa43ea3f","order_by":7,"name":"George Sefa Adai","email":"","orcid":"","institution":"Department of Educational Research, Statistics, Measurement and Evaluation, University of Calabar, Calabar, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"George","middleName":"Sefa","lastName":"Adai","suffix":""},{"id":453133167,"identity":"97de5820-f73e-4a16-9afb-5be50dafae2e","order_by":8,"name":"GinaMarie Piane","email":"","orcid":"","institution":"Department of Community Health, College of Professional Studies, National University, San Diego, California, USA","correspondingAuthor":false,"prefix":"","firstName":"GinaMarie","middleName":"","lastName":"Piane","suffix":""},{"id":453133170,"identity":"9c121657-344e-4b00-8391-3ddad427096a","order_by":9,"name":"Antor Odu Ndep","email":"","orcid":"","institution":"Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Antor","middleName":"Odu","lastName":"Ndep","suffix":""}],"badges":[],"createdAt":"2025-04-05 13:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6382388/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6382388/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82328172,"identity":"93baf5c8-b8a8-4e24-8c29-48f15b759ece","added_by":"auto","created_at":"2025-05-09 06:42:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":720425,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6382388/v1/d49e60b1-b720-41fc-8f11-e23730129079.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An experience-informed qualitative narrative of factors influencing choice of birthplace among suburban women of Calabar Municipality, Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMaternal healthcare services are an important element of women's health and include a variety of medical and support services offered throughout pregnancy, delivery, and the postpartum period [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These services are essential for the health and well-being of both mothers and babies, and they help to reduce maternal and infant mortality rates. Access to appropriate maternal healthcare services is a fundamental human right, yet many women worldwide continue to encounter severe challenges in receiving these critical treatments [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In many low and middle-income countries, maternal healthcare services are frequently insufficient, unavailable, or prohibitively expensive, leading to poor health outcomes for women and their families [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Major maternal healthcare services include prenatal care, postnatal care, child health, and childbirth services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Childbirth services in Africa are majorly delivered by primary health centers (PHC), and different factors affect the uptake of these services by women [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDifferent studies across several regions in Africa have brought to light some significant factors affecting the choice of birthplace among pregnant women [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A study in western Ethiopia revealed that personal factors such as maternal age and level of education were significant influencers of choice of birthplace among the respondents [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Societal factors were also seen to be of some consequence, and these include the infrastructural state of PHCs, proximity to health facilities, availability of health facilities, poor referral system, and the wealth of available skilled attendants [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A corresponding study conducted in Ghana revealed that statistically significant variables as regards choice of birthplace among women included level of education, manner of treatment of pregnant women by hospital staff during labor, experience with previous childbirths, and accessibility of antenatal care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Another study in Uganda revealed choices influencing birthplace among the respondents ranged from personal factors such as financial dependency to community factors such as societal perceptions towards natural birth methods [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, another study in Sierra Leone shows a little nuance from the studies highlighted above, revealing that knowledge levels of intimate partner violence (IPV) were the major influencing factor of choice of birthplace among women [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Other influences were cited in that study, including proximity to health facilities and the number of antenatal care visits [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies in Nigeria have analyzed influencing factors for choice of birthplace [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For instance, a study in the South-Eastern revealed that pre-planning to deliver at a hospital, occurrence of labor at night, and inconvenience of labor in allowing time for transportation were significant determinants of child delivery location [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A similar study in Ebonyi state highlighted the attitude of PHC workers, cost of health services, number of antenatal visits, and labor complications as some determinant factors of choice of delivery location among the respondents [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These findings, which are similar to those of the studies in other regions of Africa, suggest a similitude of experiences in Nigeria and other African countries [\u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This study looks to add information to the already existing body of knowledge by considering factors influencing the choice of birthplace among pregnant suburban women of Calabar municipality, specifically in Nigeria. This is intended to identify further nuances and underlying influences of choice of birthplace, providing a springboard for deeper exploration of this topic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design, population, and sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used a descriptive qualitative design to elicit participants\u0026rsquo; opinions and factors influencing their choice of childbirth place among pregnant women. This approach allows for the expression of ideas and experiences that may otherwise be unaccounted for in structured interviews. The researchers utilized the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide the description and reporting of this study [20]. The nature of this study focused on understanding the different viewpoints and in-depth information of pregnant women, traditional birth attendants (TBAs), and healthcare workers (HCWs) regarding the influencers of childbirth location and care. The target population included pregnant women and TBAs in the community and the HCWs within the selected primary healthcare centres (PHCs). The study was conducted in Calabar Municipality, which doubled as the state capital and a local government area (LGA) in Cross River State, Nigeria. The study setting was chosen because of the existing longstanding relationship between the study team and the participants. Christianity, followed by Islam, is the widely practised religion in the LGA. Trading, industrial activities, and civil service occupations are the key economic activities in the Calabar Municipal [21]. Popular opinion has it that most pregnant mothers in this LGA utilize TBA compared to modern healthcare during childbirth because of their beliefs, low cost, and other perceptions. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWomen of reproductive age in the communities were approached with the support of local researchers dwelling in the study location, following the approval from the community leaders in Calabar Municipal. The objectives and structure of the study were explained in Efik, Qua, and Pidgin English (which are the common languages spoken in the area). Those who voluntarily consented to participate were subsequently recruited using a convenience sampling technique, followed by a snowballing sampling approach over two months. In parallel, as TBAs appear to be the closest personnel for childbirth in the communities, it was essential to recruit them to grasp the factors influencing pregnant women\u0026rsquo;s choice of childbirth from their perspectives. Also, HCWs, as the main professionals responsible for quality childbirth, treatment response, and clinical intervention, were recruited in the study. As skilled birth attendants, their perspectives were crucial in understanding the factors influencing the choice of childbirth location. Key Informant interviews (KII) were conducted among TBAs and HCWs, while the focus group discussion (FGDs) was conducted for pregnant women. Ten interviews were conducted among TBAs and HCWs, while three FGD sessions were conducted among pregnant women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection procedure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collection was conducted using pre-designed KII and FGDs guides. The guides were adapted from existing literature [22,23] with the support of subject experts. Following the development of the guides, a pre-test exercise was conducted among a subset of the participants in a different location. Feedback from the exercise, which included rewording of questions and the removal of double-barreled questions, was incorporated into the guides. Some examples of the questions in the guides include: \u0026ldquo;What influences the choices that you make about where to deliver?\u0026rdquo;, \u0026ldquo;What factors may keep you from delivering at your first choice?\u0026rdquo;, \u0026ldquo;Imagine yourself ready to give birth, what is your first choice of where you will deliver the baby?\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eBefore data collection, the research team provided a detailed information sheet outlining the purpose and procedures of the study. After addressing any questions and concerns, informed consent was obtained from all participants (i.e., pregnant women, TBAs, and HCWs) through signed consent forms. Following this, the participants were asked to choose their preferred time and location for the face-to-face interviews and focus group. In line with the recommendations by Fusch and Ness (2015), data were collected by experienced qualitative researchers, including public health and social science experts, until the saturation was reached or the point at which the information collected was enough for answering the research questions [24]. The data were collected in Efik and Pidgin English, and each session began with some icebreakers to stimulate conversation, and each participant was encouraged to share their insights freely. When participants expressed hesitation or concerns about a particular question, the researcher adjusted the approach by rephrasing the questions, explaining further, or moving to other questions. Each of the KII lasted between 20- 30 minutes, while the FGDs spanned between 30-50 minutes. The data were audio-recorded for analysis. The research employed a reflexive approach to data collection by organizing a debriefing session at the end of each data collection to examine the challenges and address any concerns before subsequent KII and FGD sessions. No repeated interviews or follow-ups were conducted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis and reporting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recorded data were transcribed into English by local researchers with support from the research team. Appropriate translation and back-translation were done by the research team to ensure that the context closely reflects the insights from the participants. An inductive (bottom-up) and deductive (top-down) approach was used to code the data according to previous guidelines [25,26]. Before analysis, two independent researchers read and familiarized themselves with the transcripts while generating the initial codes. Discrepancies or conflicts arising from the coding exercise were discussed until a consensus was reached. Thereafter, the transcripts were imported to NVivo v12 for indexing and analysis. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe leveraged a narrative and storytelling analysis approach to report findings from this study. Narrative analysis serves as a vehicle through which stories are documented in a clear sequential order by giving meanings to experiences [27]. Furthermore, narratives aim to evoke complex events or experiences coherently while revealing the underlying ontology that participants or storytellers communicate [28,29]. The researchers took a neutral position while allowing the true narration of each participant\u0026rsquo;s quote to fit into each code category. The categories were developed by the entire research team for alignment, and the code groups were compared and refined iteratively to develop final themes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrustworthiness\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researchers engaged in open dialogue throughout all stages of the study, especially during data analysis. Given that most of the researchers are experienced in qualitative studies among pregnant women and maternal and child health-related topics, several discussions were held with qualitative experts while generating the codes and code groups. We ensured that the coded insights were cross-checked with the participants to ensure that their insights were accurately captured. Furthermore, direct quotes from the data were captured in reporting the data to enhance the transferability of the insights from participants. \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSeven themes emerged from our findings representing the influencing factors for choice of birthplace: i) Unpredictability of labor and situational constraints, ii) Preference for personal choice and comfort, iii) PHC accessibility and staff behavior, iv) Financial constraints and cost considerations, v) Importance of prenatal care and health practices, vi) Complications and referral challenges, vii) Cultural practices and community influence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnpredictability of labor and situational constraints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents usually described how the unpredictable nature of work, coupled with circumstances such as timing and transport, disrupted their choice to deliver at the place of their preference, often pushing them to turn to substitutes such as Traditional Birth Attendants (TBAs) or even in unexpected locations. They identified the abrupt nature of labour onset as a determining factor, how it could overpower intentions to reach a hospital, and how distance to Primary Health Care (PHC) facilities was often hampered by operating constraints, i.e., restricted hours, that were incompatible with the unforeseen timing of labour.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Like I said before, I think it is the situation. The situation is that the labour just happens. And they cannot get to decide. You have heard about people who give birth inside the taxi. While going to the hospital. I think they might want to go to the hospital. And the situation is not conducive.\u0026quot;\u003c/em\u003e (Speaker 5, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;So, what happened was I was just going out, and it was so hot, so I was just doing exercise. So, when I got to that health center, the door was locked, and that was 6 pm. So, the next day when I was still walking around, it was around in the morning, and the place was still locked.\u0026quot;\u003c/em\u003e (Speaker 6, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Transportation? Somehow, because sometimes the husband might not be there, and it is difficult to even raise transport to the hospital\u0026quot;\u0026nbsp;\u003c/em\u003e(Interviewee, HCW 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreference for personal choice and comfort\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents emphasized the role of personal comfort and preference in the decision to deliver at home or with Traditional Birth Attendants (TBAs) rather than Primary Health Care (PHC) centers. Personal preferences, tied to familiarity and the desire for a quiet birthing experience, often outweighed institutional options as women prioritized autonomy and well-being over medically formal settings. The notion of delivering in a familiar and peaceful environment emerged as a key driver for many women, while some further elaborated on the cultural and personal appeal of home births. Satisfaction with TBAs further reinforced choices, as participants appreciated their alignment with personal needs and comfort.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If you are okay with your pregnancy and somebody can attend to you at that time of the pregnancy. You can deliver in your house. Quietly. Peacefully, and so it is a personal choice. Yes.\u0026quot;\u003c/em\u003e (Speaker 5, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Because some people see that delivering in the house when you do not have an issue is a very good thing. Some people will stay in the house and deliver on their own.\u0026quot;\u003c/em\u003e (Speaker 3, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;ll still say it\u0026apos;s Choice. If everything is okay. The services are okay, the environment is okay, the distance is okay and the charges are okay, then, that\u0026rsquo;s fine.\u0026quot;\u003c/em\u003e (Speaker 4, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHC accessibility and staff behavior\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents reported significant difficulties with Primary Health Care (PHC) facilities, including poor accessibility and poor relations with the staff, which ultimately discouraged them from using these services compared to Traditional Birth Attendants (TBAs). The unpredictability of labor clashed with restricted PHC availability, leaving women feeling unsupported at critical moments. Staff behavior further compounded these accessibility issues, with participants describing encounters marked by impatience and insensitivity. Participants noted a pattern of dissatisfaction rooted in operational barriers and perceived lack of empathy, highlighting how these factors undermined trust in PHC systems and influenced delivery preferences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;So, I was just like, what if I\u0026apos;m in labor in the morning or it happened at night. Yeah, that was where I registered first. So, when I went back, I was just like, no, I don\u0026apos;t think that health center is okay for me. Because this labor of a thing, nobody knows it can happen any time.\u0026quot;\u0026nbsp;\u003c/em\u003e(Speaker 6, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Those nurses were shouting at me. It was so annoying. Like I was losing my baby. See the way I was bleeding. They told me to be patient and calm down. They started shouting. So, impatience. Impatience. I don\u0026apos;t like it.\u0026quot;\u003c/em\u003e (Response 2, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I decided to use the ABC facility when I lost my first baby. It was in the hospital. But when all the money that we spent, they did not even show concern. They just said, Madam, be fast. And I was not feeling well. Madam, be fast. Just call your husband.\u0026quot;\u0026nbsp;\u003c/em\u003e(Speaker 4, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Some say the nurses used to shout at them too much. Cross-infection, transfer of infection, either the baby.\u0026quot;\u003c/em\u003e (Interviewee, HCW 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial constraints and cost considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported the cost of hospital/PHC delivery and services as the major determinants of their utilization of TBAs or home delivery. Out-of-pocket payment at hospitals was a major disincentive, particularly in the event of emergencies, as the cost of hospital services deterred the participants, given their economic status. In contrast, TBAs were perceived as more accommodating, offering care that aligned with participants\u0026rsquo; economic realities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;My challenge is that when you are in the hospital, you don\u0026apos;t have patience. In terms of finances, when you get there, If you don\u0026rsquo;t have money, you might not be admitted immediately\u0026quot;\u003c/em\u003e (Speaker 3, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The money aspect, yeah, is something to consider because I have someone that even went, and the woman was the one taking care of the mother and even buying the child milk. So they don\u0026rsquo;t charge much because they know women face difficulties\u003c/em\u003e.\u0026quot; (Interviewee, HCW 3)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Again, if in your first experience, you were not treated well, maybe the person was harsh on you, maybe the charges, the hygiene condition of the place, and all those things, you were not well taken care of, I don\u0026rsquo;t think you would like to go back there.\u0026quot;\u003c/em\u003e (Interviewee, HCW 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImportance of prenatal care and health practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a strong emphasis among participants on the importance of prenatal care and health practices to ensure maternal and fetal well-being. Respondents noted a range of proactive practices, including medical check-ups, medication adherence, nutritional awareness, and hygiene. A key aspect highlighted was the necessity of regular medical engagement and diagnostic testing. Also, nutrition was another prominent focus, with participants advocating for specific dietary practices to support a healthy pregnancy. Additionally, there was a cautious approach to medication use outside professional guidance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;To stay safe. You take your medication, exercise, and go for check-ups. You run your tests. Very important. To know your HIV status, malaria. Because when you test, there are some sicknesses you have.\u0026quot;\u003c/em\u003e (Speaker 2, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;To stay healthy during pregnancy. Okay. You eat fruit. Most importantly, to eat fruit. Drink enough water. Do not eat [too much] meal and food until the baby is not too fat\u0026quot;\u003c/em\u003e (Speaker 1, TBA Centre 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We have said it already: come to the facility, take their drugs, hygiene is very important, eat good food, fruits, vegetables, and take their drugs\u0026quot;\u003c/em\u003e (Interviewee, HCW 4)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I would advise them to eat a balanced diet and eat fruits. And if they have any challenges, they should not buy drugs outside. They can only buy paracetamol\u0026quot;\u003c/em\u003e (Interviewee, HCW 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications and referral challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConcerns regarding complications of childbirth and challenges of referrals, particularly where deliveries occur with TBAs rather than PHC facilities, were identified. Risks of delayed recognition and management of complications by TBAs were mentioned by participants, contrasting this with the perceived functionality of PHC referral systems, and also remarking on the responsive nature of pursuing higher levels of care. A recurring theme was the comparative advantage of PHCs in promptly addressing complications through referrals, noting that TBAs may attempt initial interventions, potentially delaying critical hospital transfers and increasing the risk of adverse outcomes, such as fetal loss.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Primary Health Center is better than TBA. There are some cases in the Primary Health Center, they will refer you to the hospital immediately. But in TBA, they will have to tell you, okay, wait, let\u0026rsquo;s give you this first. Let\u0026rsquo;s do this. And some people, in some cases, you might lose the baby.\u0026quot;\u003c/em\u003e (Speaker 6, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When there are complications, that is when they will come. Many of them that register here still go to TBAs on the day of delivery, and many of them want to refer them back when it is out of hand (when TBAs cannot handle them); they now run down here.\u0026quot;\u003c/em\u003e (Interviewee, HCW 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If I cannot deliver by myself, you have a completed issue, you will be referred to the hospital. At times, the midwife is the one to refer you to the hospital\u0026quot;\u003c/em\u003e (Interviewee, TBA 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The women utilizing our PHC here are safe, but those in TBAs if not checked, will have Complications during childbirth. After delivery, some will have discharge, others will have bleeding, and some will retain the placenta membrane.\u0026quot;\u003c/em\u003e (Interviewee, HCW 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural practices and community influence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe role of cultural practices and community influence in shaping women\u0026rsquo;s choices regarding childbirth emerged as an important theme, often favoring Traditional Birth Attendants (TBAs) over institutional healthcare settings. Participants highlighted how traditional beliefs, familial advice, and spiritual practices intertwine to guide delivery preferences, reflecting reliance on community networks and cultural norms. A significant cultural factor identified was the influence of modesty and familial guidance. For some respondents, spiritual practices, community support, and spiritual reassurance also emerged as key influences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Maybe some might be among friends, they might say no need to go out to doctor to go and see your nakedness, it\u0026rsquo;s only for your husband. Some, the mother will say, \u0026lsquo;Don\u0026rsquo;t go, I have somewhere you can deliver safely, even my friend.\u0026rsquo;\u003c/em\u003e\u0026quot; (Interviewee, HCW 3)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Even when I came back from the hospital, I had to come here. They prayed for me. They said, don\u0026rsquo;t worry\u003c/em\u003e. \u003cem\u003eAnd also maybe you attend some fasting. Even your child, they have fasting. They pray and fast.\u0026quot;\u003c/em\u003e (Speaker 4, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Like my experience, and I always do it when they come I will first tell them register in the hospital before they come to me, even if they come to me I will say you will go the hospital and register should in case, because this life is not a human being own only God.\u0026quot;\u003c/em\u003e (Interviewee TBA 2)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFindings from our study revealed that unpredictability of labor and situational constraints were among the predictors of choice of birthplace among women. Participants indicated that the uncertainty of labor constitutes a major determinant of the location of child delivery. The occurrence of labor at odd times has made pregnant women eventually deliver at unplanned places [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This could be their place of work, a friend's residence, their homes, or even in vehicles. Participants in the study also indicated that these situational constraints made them opt for TBAs instead of skilled birth attendants (SBAs) at PHCs. This could be because the residential location of the participants (suburbs of Calabar municipality) may be distant from healthcare facilities. Results from the study also showed that financial constraints and cost considerations are another factor fostering the preference of TBAs over PHCs. Generally, professional healthcare services demand higher costs than TBAs, and this is a major reason for increased subscription to traditional birth methods [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In addition to this, a previous study in Nigeria has shown that TBAs offer better hospitality and care than SBAs, and this doubles down as an advantage for TBA users [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Findings from studies in Kenya were corroborative of results from this study, which show that financial considerations inspired the study respondents to favor TBAs over PHC delivery [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Allou (2018) also highlights that in Ghana, cost-effectiveness was one of the major drivers of the preference for TBAs over SBAs. These findings suggest that TBAs are a cheaper option in child delivery compared to PHCs [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants from this study also indicated that preference for personal comfort is another driver of the preference for TBAs over PHCs concerning child delivery. The focus group discussants reported that they prefer the autonomy, well-being-oriented, and quiet birthing experience of TBAs over the sophisticated and medically formal setting of hospital facilities. This could stem from their experience of poor quality of care from PHC staff. The study respondents indicated that their experiences with PHC staff were marked by impatience, insensitivity, and lack of empathy, and this essentially undermined their trust in PHC staff. Improper quality of care from hospital staff, regardless of their wealth of adequate equipment, can discourage women from seeking professional healthcare [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Harsh and insensitive treatment can constitute a mental health stressor for women in labour and may jeopardize childbirth outcomes [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. To this effect, friendly and hospitable care is a major driver for preference of TBAs over SBAs by African women [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Corresponding studies in Ethiopia showed similar results, as hospitality and good care were drivers of traditional delivery preference among Ethiopian women [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Results from our study also showed that poor accessibility to PHC facilities was another difficulty pregnant women experienced in childbirth. Participants reported that PHC facilities' inaccessibility and unavailability intersected with unpredictable labor occurrences to render pregnant women helpless at critical moments. This suggests that the residence of the participants on the outskirts of the Calabar town is disadvantageous, as it makes them distant from healthcare facilities within the town region. Additionally, this calls for a need to increase the availability of PHC facilities, as participants indicated that the unavailability of healthcare workers was an issue they faced.\u003c/p\u003e \u003cp\u003eUpholding cultural practices and community influence was another emergent influencer of birthplace, as shown in the results of this study. Participants highlighted that traditional beliefs, familial advice, and spiritual practices intertwined to guide their delivery preferences. Generally, cultural, religious, and community factors hold a strong sway in informing people's decisions in Africa [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. This is because culture and familial trends are held in high regard. To this effect, not following the trends could result in one being treated as an outcast or not regarded as an integral member of the community [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. This may be one of the major reasons women residing in African rural localities opt for natural birth methods and not professional healthcare. However, some participants in our study favored PHC over TBAs. These participants indicated that delayed recognition and handling of birth complications were major challenges discouraging them from subscribing to TBAs or home delivery. Given that professional healthcare has more competent equipment and personnel, they are deemed more reliable in handling birth complications than TBAs. This stands as an advantage over traditional delivery services. This assertion is drawn from the fact that in some cases, TBAs are not able to complete a medical procedure they engaged in, leading to more severe complications or even death [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Additionally, TBAs' deficiency in medical equipment makes them resort to unhygienic practices such use of unsterile equipment, delayed cord cutting, and unsafe disposal of placenta. These contribute to serious risk factors in maternal health.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003eThe qualitative technique utilized in this study considers the participants' life experiences to provide a profound grasp of their perspectives. Furthermore, by using open-ended questions, the approach of this study allowed for flexibility in data gathering, which stimulated the exploration of novel ideas and the discovery of relevant new topics and hypotheses. Additionally, the small sample size employed in this study provides some cost-effectiveness in enabling the examination. However, because of the small sample size and the fact that this study only employed a qualitative approach, these findings cannot be readily extended to a larger population. Hence, we call on longitudinal studies using multi-method studies to explore this research area.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFindings from this study highlight the need to upscale the availability and accessibility of PHCs, as limited access emerged as a major barrier to the utilization of professional healthcare services. The preference for TBA over SBA was largely due to poor hospitality and care offered by PHC workers. This highlights the importance of fostering empathetic and compassionate care by PHC staff to encourage greater uptake of professional healthcare services. Additionally, the high costs associated with professional healthcare services were a major deterrent for low utilization. There is an urgent need to address the financial burden through cost reduction, health insurance financing, or subsidizing services is essential to enhance maternal and child health outcomes while promoting equitable care to skilled birth care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOREQ: Consolidated criteria for reporting qualitative research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFGD: Focus group discussion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCWs: Healthcare workers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKII: Key Informant interviews\u003c/p\u003e\n\u003cp\u003eLGA: Local government area\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHC: Primary health centers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSBAs: skilled birth attendants\u003c/p\u003e\n\u003cp\u003eTBAs: Traditional birth attendants\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical consideration and consent to participate:\u0026nbsp;\u003c/strong\u003eOur study complied with the 2013 Declaration of Helsinki [30]. Ethical clearance was obtained from the Research and Ethics Committee of the Cross River State Ministry of Health (Approval number: CRSMH/HRP/REC/2024/477). The interview and discussion guides gave no room for the names and specific identities of respondents, and the confidentiality of information provided was assured and maintained throughout the research, data analysis, and presentation of findings. Written consent was obtained from participants before data collection. Any data obtained from participant(s) who revoked consent was destroyed and not used for the analysis. The data were stored and were only accessible to the study team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data relevant to the study are included in the article or uploaded as supplementary information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information:\u003c/strong\u003e The authors received no funding for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: MEA conceptualized the study. MEA, UFI, and PCA collaborated on the study design and ethical approval. MEA, PCA, UFI, CKO, ACU, PNT, GSA, and AON conducted the data collection, while PCA performed the data analysis. MEA, PCA, UFI, CKO, ACU, PNT, GSA, GMP, AON, and TA wrote the initial draft of the manuscript. PCA, UFI, and TA contributed to the critical review and revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors appreciate all participants in this study. Also, we extend our thanks to the community leaders and authorities for their valuable contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKifle D, Azale T, Gelaw YA, Melsew YA. Maternal health care service seeking behaviors and associated factors among women in rural Haramaya District, Eastern Ethiopia: a triangulated community-based cross-sectional study. Reprod Health. 2017 Jan 13;14(1):6. \u003c/li\u003e\n\u003cli\u003eSarikhani Y, Najibi SM, Razavi Z. 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The impact of interprofessional incivility on medical performance, service and patient care: a systematic review. Future Healthc J. 2023 Mar 1;10(1):69\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eMumtaz Z, Sivananthajothy P, Bhatti A, Sommer M. \u0026ldquo;How can we leave the traditions of our \u003cem\u003eBaab Daada\u003c/em\u003e \u0026rdquo; socio‐cultural structures and values driving menstrual hygiene management challenges in schools in Pakistan. J Adolesc. 2019 Oct;76(1):152\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eChauhan A, Potdar J. Maternal Mental Health During Pregnancy: A Critical Review. Cureus. 2022 Oct;14(10):e30656. \u003c/li\u003e\n\u003cli\u003eTaye BT, Zerihun MS, Kitaw TM, Demisse TL, Worku SA, Fitie GW, et al. Women\u0026rsquo;s traditional birth attendant utilization at birth and its associated factors in Angolella Tara, Ethiopia. PloS One. 2022;17(11):e0277504. \u003c/li\u003e\n\u003cli\u003eAppiah R, Raviola G, Weobong B. Balancing Ethics and Culture: A Scoping Review of Ethico-Cultural and Implementation Challenges of the Individual-Based Consent Model in African Research. J Empir Res Hum Res Ethics JERHRE. 2024 Jul;19(3):143\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eKassie A, Wale A, Girma D, Amsalu H, yechale M. The role of traditional birth attendants and problem of integration with health facilities in remote rural community of West Omo Zone 2021: exploratory qualitative study. BMC Pregnancy Childbirth. 2022 May 20;22(1):425. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Traditional birth attendants, maternal health, qualitative study, narrative analysis, choice, birthplace","lastPublishedDoi":"10.21203/rs.3.rs-6382388/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6382388/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn many low and middle-income countries, childbirth services are frequently insufficient, unavailable, or prohibitively expensive, leading to poor health outcomes for women and their families. Primary health centers majorly deliver limited childbirth services in Africa, and different factors affect the uptake of these services by women. Our study aimed to investigate the factors influencing the choice of birthplace among the suburban population of Calabar Municipality in Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study used a descriptive qualitative design to elicit participants\u0026rsquo; opinions and factors influencing the choice of birthplace among pregnant women, traditional birth attendants (TBAs), and healthcare workers (HCWs) in the Calabar Municipality. Participants were selected via convenience sampling followed by a snowball technique. Ten interviews were conducted among TBAs and HCWs, while three focus group sessions were conducted among pregnant women. Data were analyzed using a narrative analysis approach with NVivo v12.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeven themes emerged from our findings, representing the influencing factors for choice of birthplace: i) Unpredictability of labor and situational constraints, ii) Preference for personal choice and comfort, iii) PHC accessibility and staff behavior, iv) Financial constraints and cost considerations, v) Importance of prenatal care and health practices, vi) Complications and referral challenges, vii) Cultural practices and community influence.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFindings from this study highlight that the preference for TBAs was largely due to poor hospitality and care offered by PHC workers. This highlights the importance of fostering empathetic and compassionate care by PHC staff to encourage greater uptake of professional healthcare services. Since the high cost associated with professional healthcare services was a major deterrent, there is an urgent need to address the financial burden through cost reduction, health insurance financing, or subsidizing services, which is essential to enhance maternal and child health outcomes while promoting equitable care to skilled birth care.\u003c/p\u003e","manuscriptTitle":"An experience-informed qualitative narrative of factors influencing choice of birthplace among suburban women of Calabar Municipality, Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 06:26:26","doi":"10.21203/rs.3.rs-6382388/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-05-20T12:40:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62726466095599835703022574392210124175","date":"2025-05-06T08:52:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T08:00:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-09T13:57:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-07T02:48:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-07T02:47:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-05T13:37:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51d039ae-26e9-4089-867f-258a4afc2c64","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T06:26:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 06:26:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6382388","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6382388","identity":"rs-6382388","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}