Maternal mortality remains a significant public health challenge, particularly in resource-constrained economies like those in sub-Saharan Africa (SSA). In 2015, over 300,000 maternal deaths occurred globally, with 66% concentrated in SSA. Health facility delivery is recognized as crucial for reducing maternal mortality. Despite efforts to improve access to maternal care, many women in SSA, including Nigeria, still opt for home deliveries, which pose significant risks. Nigeria's maternal mortality rate (MMR) is high, at 906 per 100,000 births, partly due to the prevalence of home births. While existing research explores determinants of health facility delivery, studies incorporating community-level factors are limited. This study aims to fill this gap by investigating the determinants of non-institutional delivery among Nigerian women of reproductive age, focusing on individual, household, and community-level factors. Understanding these determinants is vital for reducing maternal mortality and achieving the Sustainable Development Goals (SDGs) target of reducing MMR to less than 70 per 100,000 live births by 2030.

Several studies have explored the determinants of health facility delivery and home births in various contexts. Research indicates that factors such as socioeconomic status, education level, geographical location, and access to healthcare services significantly influence women's choices regarding delivery locations. Studies in Nepal, Tanzania, Cambodia, and Ghana have shown varying rates of home deliveries, highlighting the diverse influences on this practice. Some studies emphasize financial and regional constraints limiting access to standard health services as key reasons for home births. Others point to a lack of information about the risks associated with home deliveries among uneducated women from poor, rural backgrounds. However, the incorporation of community-level factors in these analyses has been inconsistent. This study aims to contribute to the literature by analyzing the influence of both individual and community-level factors on women’s decisions to utilize or forgo institutional childbirth services.

This study used cross-sectional data from the 2018 Nigerian National Demographic Health Survey (NDHS). The data included 12,567 women of reproductive age (15-49 years) who had given birth in the past five years. The outcome variable was non-institutional delivery (coded 1 for home deliveries, 0 for health facility deliveries). Individual-level factors included maternal age, religion, maternal education, spouse's education, health insurance coverage, employment status, antenatal care initiation time, and women's autonomy in healthcare decisions. Household-level factors comprised household head's gender, household size, and household wealth index (measured using principal component analysis). Community-level factors were based on characteristics of enumeration areas (EAs), including urban/rural location, cultural norms regarding wife-beating, female literacy rates, community poverty levels, and community-level media access. A multilevel binary logistic regression was used to analyze the data, accounting for individual, household, and community-level effects. Five models were estimated: a null model, models with individual, household, and community factors separately, and a final model with all three levels of factors. Adjusted odds ratios (AORs) and 95% confidence intervals were reported to assess the strength and significance of associations.

The study found that 58.6% of women delivered their babies outside health institutions. Several individual, household, and community factors were associated with non-institutional delivery. Women with higher levels of education (primary, secondary, and post-secondary) were significantly less likely to have home deliveries compared to those with no formal education. Similarly, women whose partners had higher levels of education were less likely to deliver at home. Women with health insurance coverage were also less likely to opt for home births. Household wealth also played a role; women from wealthier households were less likely to deliver at home. Residential location had a substantial influence; women residing in rural areas were significantly more likely to have home deliveries than those in urban areas. Community-level factors revealed that women from communities with high poverty levels and low media exposure were more likely to deliver at home. Conversely, women from communities with higher media use and greater women's autonomy were less likely to choose home deliveries. The multilevel model, which incorporated all individual, household, and community-level factors, demonstrated the best fit for predicting non-institutional delivery.

The high rate of non-institutional deliveries in Nigeria highlights the need for interventions to improve maternal healthcare utilization. The findings align with existing research indicating a strong association between socioeconomic factors, education, geographic location, and healthcare access and the choice of delivery location. The study underscores the importance of community-level factors, highlighting the influence of cultural norms, media exposure, and community-level poverty on delivery choices. The finding that women with less autonomy in healthcare decisions were more likely to have home deliveries stresses the need to empower women to make informed choices about their reproductive health. The significant role of media exposure underscores the importance of targeted communication campaigns to increase awareness about the benefits of health facility deliveries.

This study identified several factors associated with non-institutional delivery among women in Nigeria. Low socioeconomic status, low educational attainment, low media exposure, rural residence, high community poverty, low community media use, and limited women's autonomy were significant predictors of home births. To address the high rates of maternal mortality and achieve the SDG target, the study calls for stronger advocacy, education initiatives (focused group discussions, peer education), improved maternal care policies (reducing costs, increasing facility accessibility), and further qualitative research to delve deeper into the complexities of home delivery choices among Nigerian women.

As a cross-sectional study, this research cannot establish causality between the identified factors and home delivery choices. The reliance on self-reported data from the NDHS may introduce recall bias. The community-level variables were based on aggregate data from enumeration areas, potentially masking variations within communities. Future research might benefit from incorporating qualitative data to explore the nuances of decision-making processes surrounding childbirth choices in Nigeria.