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Abstract
Objective To assess the prevalence of non-utilisation of postpartum services in northwestern Nigeria from 2003 to 2018 and to identify and estimate the influence of social determinants, a crucial step in improving maternal and child health in the region.
Design The 2003, 2008, 2013 and 2018 Nigeria Demographic and Health Survey rounds were used. Descriptive, trend and multivariable logistic regression analyses were used to show the trend and assess the influence of social determinants. The sample consisted of 17 294 women aged 15–49 who responded to questions on postpartum attendance during the period.
Setting Northwestern geographical subregion of Nigeria.
Outcome The non-use of postpartum services.
Results The non-utilisation of postpartum services has increased from 77% in 2003 to 87% in 2018, with an overall prevalence of 88% of all women not using the services. The odds of not using postpartum services were higher for women with no education (adjusted OR (AOR): 1.27; CI: 1.03 to 1.58), those with no knowledge of contraceptives (AOR: 1.72; CI: 1.35 to 2.19), those who never used contraceptives (AOR: 1.71; CI: 1.39 to 2.09), those with parity of four or more births (AOR: 1.58; CI: 1.34 to 1.86), those in polygynous marriage (AOR: 1.16; CI: 1.03 to 1.30) and those from the poorest (AOR: 2.34; CI: 1.67 to 3.28) and poorer (AOR: 2.05; CI: 1.50 to 2.78) households. The odds were lower for women who wanted to delay pregnancy (AOR: 0.74; CI: 0.55 to 0.99) and those with full (AOR: 0.56; CI: 0.42 to 0.75) or joint (AOR: 0.67; CI: 0.53 to 0.83) autonomy in healthcare decisions.
Conclusion The findings are crucial for understanding and addressing the non-utilisation of postpartum services in northwestern Nigeria. Policymakers should aim to address the impacts of the identified social determinants to promote the use of postpartum services, prevent maternal deaths and meet the SDG-3.1 target.
- Postpartum Period
- Public Health
- Reproductive medicine
Data availability statement
Data are available in a public, open access repository. All data are available within the manuscript, and the datasets used for this study can be accessed from the DHS program's website: https://dhsprogram.com/data/available-datasets.cfm.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Assesses the changes in non-utilisation of postpartum services and the influence of social determinants.
Due to the cross-sectional nature of the data, causality could not be established between social determinants and the non-utilisation of postpartum services.
The possibility of recall bias by the respondents cannot be overruled since the survey relies on self-reports based on past events in the respondents’ lives.
Other social determinants that could further explain the problem were unavailable in the data set, such as traditional norms around childbearing, experiences with previous births, support networks and quality of previous services.
Future research should consider using primary data to assess some of the social determinants not included in the survey.
Introduction
Women continue to die due to preventable childbirth-related causes in Nigeria. Nigeria is one of the countries with the highest maternal mortality ratio (MMR) globally, and this is due mainly to the low utilisation of skilled maternal healthcare services during childbirth and in the immediate period after. The recent estimate from the country’s Demographic and Health Survey (DHS) reported the MMR to be 512 deaths per 100 000 livebirths,1 which was twice above the Millennium Development Goals (MDG) target of 250 deaths by 2015. The Sustainable Development Goals (SDG) has set a new target (SDG-3.1) of not more than 70 deaths by 20302 and not more than 140 deaths in any country.3 Most of the maternal deaths in Nigeria happen in the northern region of the country, with estimates of more than 800 deaths per 100 000 livebirths in the northwestern zone.1 4–7 These maternal deaths are preventable should women use skilled maternal healthcare services, especially during delivery and the postpartum period.8 9
The postpartum period, which is immediately after childbirth and up to 42 days later, is a precarious stage, and most maternal deaths occur during this period. Postpartum care is critical to the health of both the mother and the newborn; it is a preventive measure against maternal and child mortality.10–12 The WHO9 13 reported that up to 30% of maternal deaths happen postdelivery, with about 60% of the deaths occurring within the first day, primarily due to postpartum haemorrhage.14 Therefore, it is strongly recommended that women be checked after childbirth at least four times within the first 6 weeks: within 24 hours of delivery, on the third day, between days 7 and 14, and 6 weeks after delivery.15 In Nigeria, it is recommended that every woman who gave birth, irrespective of place of birth, receive postpartum checks within 12 hours for home births and within 24 hours for health facility births.1 However, despite its importance to a woman’s life after childbirth, postpartum care is commonly the least of services being used by women in the continuum of maternal healthcare,16 and numerous studies have reported the very poor utilisation of postpartum services, especially in sub-Saharan African countries.10 11 15 17–25
More than 80% of women in northwestern Nigeria do not receive postpartum checks after childbirth, which is the highest in the country.1 The situation has persisted over the years but has yet to be empirically studied to understand the influence of social determinants in that subregion. The literature has identified numerous factors influencing the poor utilisation of postpartum services by women in different settings, and they include the socioeconomic status of women, geographical location, sociocultural factors, lack of access and transportation to healthcare facilities and high prevalence of home delivery due to traditional norms of childbearing, among others.11 18 21 24 26–32 However, there is an absence of evidence of the factors influencing the non-utilisation of postpartum services in the northern region of Nigeria, especially in the northwestern zone, which has the worst situation, despite the importance of geographical and social contexts.33 While the determinants are similar across countries, their influence differs in different settings, necessitating context-specific studies for appropriate policy response. Therefore, this study was undertaken to fill this gap by assessing the progress or otherwise in reducing the prevalence of non-utilisation of postpartum services in northwestern Nigeria between 2003 and 2018 and to identify and estimate the influence of the social determinants.
The northwest is the most populous of the six geographical zones of Nigeria, based on national census figures, and the zone has the poorest socioeconomic and health indicators in the country.1 34 Moreover, Nigeria is a heterogeneous country, with each subregion having its peculiar sociocultural beliefs and practices which influence healthcare services utilisation. The utilisation of maternal healthcare services has consistently been the poorest in the northwest zone.1 With the ongoing efforts to attain SDG-3.1 to reduce the MMR in the country, it is imperative to promote the utilisation of postpartum services as a preventive measure against maternal deaths. Hence, this study aims to assess the prevalence of non-utilisation of postpartum services in northwestern Nigeria from 2003 to 2018 and to identify and estimate the influence of social determinants. Assessing the trend and identifying the influential determinants during the period will enable policymakers to know what needs to be prioritised for promoting the utilisation of postpartum services to prevent maternal deaths in the subregion for attaining SDG-3.1.
Methods
Data and sample
Data from the 2003, 2008, 2013 and 2018 Nigeria DHS were used. The DHS is a household-based, country-wide survey that uses a stratified two-stage cluster sampling technique to collect relevant demographic and health information. Data were collected from households in Nigeria’s six geopolitical zones. The complete details of the methodology and sampling procedures can be found in each survey round.1 35–37 The sample consists of 17 294 women from the northwestern zone who provided information on the use of postpartum services after childbirth (figure 1).
The study sample.
Variables
Outcome variable
The outcome variable is the non-utilisation of postpartum services, categorised as a dummy variable with ‘used’ for those who received postpartum checks within 42 days after childbirth and ‘not used’ for those who did not receive. The responses were coded as ‘0’ for ‘used’ and ‘1’ for ‘not used’.
Independent variables
The independent variables were selected based on the United Nations Development Programme’s (UNDP) social determinants of maternal health framework.38 The UNDP’s framework categorised the social determinants into structural and intermediary determinants. The structural determinants include education (none; primary; secondary and higher), employment (yes; no), ethnicity (Fulani; Hausa; others), religion (Christianity and others; Islam), contraceptive knowledge (yes; no), contraceptive use (yes; no) and access to health insurance (yes; no). The intermediary determinants include the age of women (15–19, 20–29, 30–39, 40–49 years), birth parity (one; two; three; four or more), pregnancy intention (wanted then; wanted later; wanted no more), autonomy in healthcare decision (husband/someone else; alone; jointly), family structure (marital type as proxy) (monogamous; polygynous), wealth status (poorest; poorer, middle; richer; richest), place of residence (urban; rural), distance to health facility (a problem; not a problem) and cost of care (a problem; not a problem). The UNDP identified these social determinants as influential in maternal health.
Statistical analysis
The data sets for the four rounds of the DHS were extracted into a single file from the IPUMS-DHS website. The IPUMS-DHS enables the creation of a single data file from the different survey data sets. We extracted the variables of interest from the data sets into a single file and exported them into STATA analysis software V.17. Descriptive analysis was used to present the background characteristics of respondents by frequency distribution and percentage counts. The trend in non-utilisation of postpartum services was presented using a bar graph. Multivariable binary logistic regression models were fit to estimate and explain the influence of the structural and intermediary determinants of the non-utilisation of postpartum services. Each survey round was fit into one model, making four separate models, while a fifth model pooled all the rounds together as the full model. Only the statistically significant (p<0.05) determinants in any of the separate models were pooled into the full model. This was done to identify the influential determinants in the period covered and enable policymakers in the region to know which determinants should be prioritised for increasing service utilisation. Sampling weight, clustering and stratification effects were accounted for using the ‘svy’ command in STATA. The results are presented using adjusted OR (AOR) and CIs.
Patient and public involvement
Patients and the public were not involved in this study.
Results
Background characteristics of respondents
Table 1 shows the sociodemographic characteristics of the sampled respondents. The mean age of the sample was 28.9 years (SD=7.66). Almost half of the respondents (46.3%) were within 20–29 years and about one-third (32.9%) were within 30–39 years. More than three-quarters (79.9%) had no education, and an overwhelming majority were practising Islam (95.8%) and were from the Hausa ethnic group (83.1%). More than half were working (55.7%), almost all of them were married (97.7%) and more than half (56.0%) were in a monogamous marriage. Those from the poorest and poorer households constituted 37.4% and 32.6%, respectively, and the majority resided in rural areas (81.4%) at the time of the surveys.
Background characteristics of respondents (n=17 294)
Trend in non-utilisation of postpartum services
Figure 2 shows the trend in the non-utilisation of postpartum services from 2003 to 2018. In 2003, 77% of women did not use postpartum services. The prevalence increased to 87% in 2008 and 91% in 2013 before dropping slightly to 87% in 2018. Overall, 88% of all women who gave birth during the 15 years did not use postpartum services.
Trend in non-utilisation of postpartum services in northwestern Nigeria 2003–2018.
Social determinants of non-utilisation of postpartum services
The result from the individual models is provided in online supplemental table 1. It reveals that the significantly influential structural determinants of the non-utilisation of postpartum services include education (2008), employment status (2018), ethnicity (2013), religion (2008, 2013), contraceptive knowledge and contraceptive use (2003, 2013, 2018), and access to health insurance (2013). Meanwhile, the health insurance variable was not available in the 2003 round of the survey as Nigeria had no health insurance programme until 2004. For the intermediary determinants, age and place of residence were not significant in any of the individual models. Parity (2008, 2013), pregnancy intention (2003, 2008), healthcare decision autonomy (2003, 2008, 2013, 2018), marriage type (2003, 2018), wealth status (2003, 2008, 2013), distance to health facilities (2008, 2018) and cost of care (2008, 2013, 2018) were the significant determinants.
Supplemental material
Table 2 summarises the pooled model containing only the significant determinants. For the structural determinants, education, contraceptive knowledge and contraceptive use were significantly influential. The women with no education had 1.27 times (CI: 1.03 to 1.58) greater odds of not using postpartum services than those with secondary or higher education. Women who were not aware of any method of contraceptives were 1.72 times (CI: 1.35 to 2.19) more likely to not use postpartum services than those who were aware of any method. Similarly, women who never used any contraceptives had 1.71 times (CI: 1.39 to 2.09) greater odds of not using postpartum services than those who had used any method in the past.
Summary of the pooled model of social determinants of non-utilisation of postpartum services
For the intermediary determinants, parity, pregnancy intention, autonomy in healthcare decisions, marriage type and household wealth were the significant determinants. The result reveals that the women who had two births had 1.31 times (CI: 1.06 to 1.63) greater odds, those with three births had 1.30 times (CI: 1.05 to 1.61) greater odds and those with four or more births had 1.58 times (CI: 1.34 to 1.86) greater odds to not use postpartum services than those with only one birth. The women who wanted their most recent pregnancies to be later were 36% (AOR: 0.74; CI: 0.55 to 0.99) less likely to not use postpartum services than those who wanted it then. The odds of not using postpartum services were 44% (AOR: 0.56; CI: 0.42 to 0.75) lesser for those with full autonomy and 33% (AOR: 0.67; CI: 0.53 to 0.83) lesser for those who decide jointly with their husbands than for those who had no autonomy. The women in polygynous marriages were 1.16 times (CI: 1.03 to 1.30) more likely than those from monogamous marriages to not use postpartum services. The women from the poorest and poorer households had 2.34 (CI: 1.67 to 3.28) and 2.05 (CI: 1.50 to 2.78) times higher likelihood to not use postpartum services than women from the richest households.
The odds of not using postpartum services increased with time: women were 1.37 times (CI: 1.04 to 1.80) more likely in 2008, 2.13 times (CI: 1.59 to 2.87) more likely in 2013 and 2.41 times (CI: 1.85 to 3.14) more likely in 2018 to not use postpartum services than in 2003.
Discussion
As Nigeria aims to meet the SDG-3.1 target to reduce the very high maternal deaths in the country by 2030, it is imperative to promote the utilisation of maternal healthcare services all over the country. This study aimed to analyse the level of progress, if any, in reducing the very high prevalence of non-utilisation of one of the critical components in the continuum of maternal healthcare, that is, postpartum care, and to identify the social determinants and their influence for the benefit of policymakers in northwestern Nigeria. Adapting the UNDP’s social determinants framework for maternal health to understand the significantly influential social determinants over time, the study used data from the Nigeria DHS since the era of the MDGs to its successor, the SDGs.
The findings reveal that instead of recording progress the reverse is the case as the non-utilisation of postpartum services in northwestern Nigeria has increased by about 10% from 2003 to 2018. Surprisingly, numerous policies and programmes were initiated and implemented during this period to promote healthcare in the country, such as the national health and reproductive policies,39 40 health insurance scheme,41 midwives’ scheme42 and several other maternal health intervention programmes.43 44 However, the bane of most of the policies and programmes was poor implementation, lack of required financial investment and the failure to address the core of the non-utilisation of maternal healthcare services, which are the social determinants. Also, the policies and programmes do not consider differences in the sociocultural settings of the different subregions of the country; the northwest zone is predominantly rural, with a very low level of educational attainment among women, very high poverty rate, high prevalence of early and child marriages, and many other poor socioeconomic indicators.1 34 45 Hence, adopting the same approach despite the heterogeneous nature of the country has not worked in the subregion. Therefore, policymakers should pay closer attention to the northwestern zone and initiate programmes concerning its socioeconomic and cultural peculiarities to address the very high prevalence of the non-utilisation of postpartum care services. In addition, massive public awareness campaigns must be carried out in the subregion to sensitive women on the importance of using postpartum and other skilled maternal healthcare services.
The key findings on the social determinants reveal that in the overall period, education, contraceptive knowledge and contraceptive use were the significantly influential structural determinants of non-utilisation of postpartum services in northwestern Nigeria. Although the other structural determinants, such as employment, ethnicity, religion and health insurance, were significant at some point during the period, they were not influential overall. The intermediary determinants significantly influential in the overall period include parity, pregnancy intention, autonomy, marriage type and household wealth. Respondents’ age and place of residence were not significant at all, while distance to health facilities and cost of care were only significant at some point but not in the overall period.
The finding reveals that education reduces the likelihood of non-utilisation of postpartum services as women with no education are more likely not to use the services than those with secondary or tertiary education. Several studies from other developing countries have reported similar findings.17 19 24 25 29 32 46–58 The plausible explanation for the finding is that women with no education may possess limited or no knowledge of the necessity for seeking postpartum care, especially if they did not experience any difficulty during childbirth, while those with secondary or higher education may possess more access and exposure to information that facilitates utilisation of services from health facilities.47 59 Education also facilitates women’s easy decision-making about their health.24 Consequently, policymakers must ensure the promotion of education for women, especially girl-child education, which is very low in northern Nigeria. Policymakers should pay attention to some critical sociocultural factors that are hindering girls from being enrolled or allowed to complete schooling in the region, especially the endemic practice of early marriage among the Muslims and Hausa and Fulani ethnic groups.60 Girls are married early in the northern region due to the practice of betrothal by parents60 and mainly because parents want to safeguard their daughters from engaging in premarital sex and pregnancy,61 62 which is more prominent in rural areas and among the uneducated. This situation must be addressed by engaging religious and traditional leaders in discussions of the importance of women’s education for their health.
The number of children born by women is also a significant determinant of the non-utilisation of postpartum services in the study area. Our finding reveals that, generally, women with more than one birth were more likely not to use postpartum services than those with only one birth. This finding corroborates the findings of previous studies in Nigeria,25 Cote d’Ivoire, Guinea, Liberia, Sierra Leone and Niger32 and the sub-Saharan African (SSA) region,47 which reported lower odds of using postpartum services by women as the number of children increases. Usually, parity comes into play when women with more births see themselves as being experienced in childbirth such that they do not need to seek postpartum care, especially if they did not experience complications during childbirth. Other reasons for the non-utilisation of postpartum services among these women could be previous bad experiences with healthcare providers, cost of accessing care, distance to health facilities or longer waiting times.47 This situation needs to be addressed by policymakers because evidence indicates that the risk of maternal mortality and morbidity is higher for women with higher birth parity.63 64 Hence, they need to use skilled services to prevent becoming casualties.
Pregnancy intentions of women also influence the non-utilisation of postpartum services. Surprisingly, the finding reveals that women who wanted to delay their last pregnancies had lower odds of not using postpartum services than those who wanted the pregnancies then. By implication, not wanting a pregnancy does not promote non-utilisation of services. A previous study in Nigeria also reported similar findings as those who would have loved to delay their last pregnancies had lower odds of not using postpartum services than those who wanted it when they got it.25 However, a study in Kenya18 and a meta-analysis of 36 SSA countries58 found pregnancy intention to be an insignificant predictor of postpartum services use.
Contraceptive knowledge and use were also significant determinants of non-utilisation of postpartum services. Women who did not know about contraceptives and those who had never used contraceptives were more likely not to use postpartum services. Most previous studies did not consider the influence of contraceptive knowledge and contraceptive use on postpartum care services, even though it is relevant just as for other components of the maternal healthcare continuum. A study in Chad assessed the influence of contraceptive use and found those who used it had higher odds of using maternal healthcare services, including postpartum service.65
Women’s autonomy strongly influences the non-utilisation of postpartum services. Women who had full autonomy to make decisions on their healthcare and those who decide together with their husbands/partners were less likely not to use postpartum services. This finding is consistent with previous studies in Nigeria,46 53 Pakistan,51 Bangladesh,66 Ethiopia,67 Malawi54 and other African countries.32 Women’s ability to make decisions or be involved in decision-making about their healthcare ensures that they can prioritise their health and find it easier to use services without waiting for someone to permit them, which could make them not use such services. Hence, policymakers should engage religious and traditional authorities in the region to promote women’s involvement in decision-making because the religious and traditional norms primarily define this.
The findings of this study revealed that women in polygynous marriages tend to be more likely not to use postpartum services. A study in Cote d’Ivoire, Guinea, Liberia, Niger Republic and Sierra Leone32 has also found women in polygynous marriages to have less likelihood of using postpartum services. The study in Chad65 also found that women in polygynous marriages were less likely to use maternal healthcare services, including postpartum care. Policymakers should pay attention to this and involve men in maternal health promotion programmes as critical stakeholders and heads of households. Involving men in reproductive and maternal health has been acknowledged as relevant to promoting maternal health and services uptake.68–70 When men are involved and enlightened about the necessity of using postpartum services, it will make it easier for women to attend health facilities for care.65
Non-utilisation of postpartum services was higher among women from the poorest and poorest households than those from the richest households. The odds for the poor categories were twice that of the richest category. Several studies have reported a similar pattern in the influence of household wealth on the non-utilisation or utilisation of postpartum services.17 19 24 25 46 47 50 51 53 55 Household wealth impacts the affordability of healthcare services.67 71 Women from poor households are often economically not empowered and may find it challenging to afford to pay for services, medications and transportation to health facilities to access care.46 72 Although maternal healthcare services are mainly offered free in public health facilities in northwestern Nigeria, women usually need to pay for transportation to health facilities, especially in rural areas that lack such facilities within shorter distances. This becomes a barrier and promotes the non-utilisation of postpartum services.
The likelihood of not using postpartum services in the subregion tends to increase with time. It was highest in 2018 and 2013 compared with 2003. This points to the lack of success in promoting postpartum service uptake, as seen from the trends in non-use of the service between 2003 and 2018. Policies and programmes must be tailored to the peculiarities of each of the subregions of the country due to their heterogeneity as the uniform approach being adopted has not produced the same results in all places. The northwestern zone of Nigeria is a socioeconomically backward subregion with large proportions of uneducated and rural population strictly adhering to religious and traditional practices. Hence, involving religious and traditional leaders will be necessary to promote increased utilisation of postpartum services and reduce maternal deaths and morbidities to attain SDG-3.1.
This study has some limitations. Using cross-sectional data implies that causality between social determinants and non-utilisation of postpartum services could not be established. Also, we cannot rule out the possibility of recall failures by the respondents since the DHS is retrospective as questions refer to events that occurred in the previous 5 years before the survey. Other important social determinants that could explain the problem were unavailable in the data set, such as childbearing norms, experiences with previous births, support networks and quality of previous services. Notwithstanding, the study has revealed some significant findings that could help policymakers understand why non-utilisation of postpartum services has remained very high in the subregion to initiate appropriate programmes to address the problem.
Conclusion
As Nigeria struggles to meet the target of SDG-3.1 to reduce maternal deaths by 2030, this study assessed the level of progress from efforts to increase postpartum services and identified the social determinants that influenced the non-use of the service. The findings are crucial for understanding and addressing the non-utilisation of postpartum services in northwestern Nigeria. The findings have shown no progress in promoting the uptake of postpartum services, which is a significant concern. Policymakers should aim to address the impacts of the identified social determinants to promote the use of postpartum services, prevent maternal deaths and meet the SDG-3.1 target. Public enlightenment campaigns on the dangers of not using skilled maternal healthcare services, especially postpartum services, and the involvement of critical local stakeholders such as religious and traditional leaders and men in the region can produce better outcomes.
Data availability statement
Data are available in a public, open access repository. All data are available within the manuscript, and the datasets used for this study can be accessed from the DHS program's website: https://dhsprogram.com/data/available-datasets.cfm.
Ethics statements
Patient consent for publication
Ethics approval
This study used secondary data collected by the National Population Commission (NPC). The NPC obtained ethical approvals from the Health Research and Ethics Committee of the Federal Ministry of Health of Nigeria before each survey round. Hence, we do not need ethical approval for this study. However, we obtained approval to use the dataset from the DHS program through the website https://www.dhsprogram.com/ and a certificate of exemption (COE. No. 2023/11-220) from the Institutional Review Board of the Institute for Population and Social Research, Mahidol University, Thailand.
Acknowledgments
The authors thank the DHS program for granting access to the data sets for this study.
References
Footnotes
Contributors AAY contributed to the conceptualisation, design, analysis and discussion and wrote the first draft of the manuscript. YS and DAW contributed to the conceptualisation, design and analysis and reviewed the manuscript draft. PH contributed to the design and analysis and reviewed the manuscript draft. All authors read and approved the manuscript. YS is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.