Psychosocial Influences on Pregnancy and Childbirth Behaviours in North-western Nigeria: A Cross-sectional Analysis

"Ideational metrics provide important insights for programmes that aim to change health behaviours, including pregnancy and childbirth, and should be explored for other health areas as well."

Antenatal care (ANC) and facility delivery are essential maternal health services, but uptake remains low in northwestern Nigeria. This study aimed to assess the psychosocial influences on pregnancy and childbirth behaviours in Nigeria. Data were from a survey conducted in September 2019 in Kebbi, Sokoto, and Zamfara states in northwestern Nigeria within wards designated for a social and behaviour change (SBC) programme to help improve the health and well-being of women and children. The study analysed baseline survey data collected prior to initiation of the SBC programme.

As part of this two-stage cluster-sample cross-sectional survey, women with a child under 2 years were asked about their maternal health behaviours during their last pregnancy. Psychosocial metrics were developed using the Ideation Model of Strategic Communication and Behaviour Change, which theorises psychosocial factors to consist of three ideational domains - cognitive, emotional, and social - with each domain consisting of specific behavioural influences. Predicted probabilities for visiting ANC four or more times (ANC4+) and giving birth in a facility were derived using mixed-effects logistic regression models adjusted for ideational and socio-demographic variables.

Across the study area, there were low levels of ANC4+ attendance and facility-based delivery among women aged 15-49 years during her last pregnancy in the past 2 years. Among the 3,039 sample women, 23.6% (95% confidence interval (CI): 18.0-30.3%) attended ANC4+ times, and 15.5% (95% CI: 11.8-20.1%) gave birth in a facility. The study findings suggest that cognitive, emotional and social psychosocial factors play an important role in the study women's pregnancy and childbirth decisions, which are shaped by the broader socioeconomic, cultural, and health system contexts of the region. For example:

• Among women who did not attend ANC4+ times or have a facility-based delivery during their last pregnancy, the most commonly cited reasons for non-use were lack of perceived need (42% and 67%, respectively) and spousal opposition (25% and 27%, respectively).
• Women who knew any ANC benefit or the recommended number of ANC visits were 3.2 and 2.1 times more likely to attend ANC4+ times, respectively.
• Women who held positive views about health facilities for childbirth had 1.2 and 2.6 times higher likelihood of attending ANC4+ times and having a facility delivery, respectively, while women who believed ANC was only for sickness or pregnancy complications had a 17% lower likelihood of attending ANC4+ times. Self-efficacy and supportive spousal influence were also significantly associated with both outcomes.

Thus, ANC knowledge and beliefs, self-efficacy in accessing services, spousal support in pregnancy and childbirth decisions, and positive perceptions of maternal health services quality were found to be among the most important ideations for SBC programmes to target in northwestern Nigeria in relation to improving ANC4+ attendance and facility-based delivery. That is, the focus could be on: raising knowledge and dispelling myths, building women's confidence to access services, engaging spousal support in decision-making, and improving perceived (and actual) maternal health services quality. As the researchers stress, such efforts must by complemented by health system strengthening efforts and other programmes that address entrenched gender and social norms that reduce women's participation in healthcare decision-making.