J.biosoc.Sci, page 1 of 10, 
 2007 Cambridge University Press
doi:10.1017/S0021932007002520
ATTITUDE AND PREFERENCES OF NIGERIAN
ANTENATAL WOMEN TO SOCIAL SUPPORT
DURING LABOUR
I. O. MORHASON-BELLO*, O. OLAYEMI*, O. A. OJENGBEDE*,
B. O. ADEDOKUN†, O. O. OKUYEMI*  B. ORJI‡
*Department of Obstetrics & Gynaecology, University College Hospital, Ibadan,
Nigeria, †Department of Epidemiology, Medical Statistics and Environmental Health,
College of Medicine, University of Ibadan, Nigeria and ‡Center for Population and
Reproductive Health, College of Medicine, University of Ibadan, Nigeria
Summary. This was a hospital-based cross-sectional study of 224 randomly
selected antenatal women receiving care at the University College Hospital,
Ibadan, Nigeria. The study aimed to seek the attitude and preferences of
respondents about social support during childbirth and also identify variables
that may influence their decisions. Seventy-five per cent of respondents
desired companionship in labour. Approximately 86% preferred their hus-
band as companion while 7% and 5% wanted their mother and siblings as
support person respectively. Reasons for their desire for social support were
emotional (80·2%), spiritual (17·9%), errands (8·6%) and physical activity
(6·8%). Socio-demographic variables found to be statistically significant on
logistic regression analysis for the desire of a companion in labour were
nulliparity (OR 3·57, 95% CI 1·49–8·52), professionals (OR 3·11, 95% CI
1·22–7·94) and women of other ethnic groups besides Yoruba (OR 2·90, 95%
CI 1·02–8·26), which is the predominant ethnic group in the study area. Only
those with post-secondary education were found to want their husbands as
doula (OR 2·96, 95% CI 1·08–8·11). More than half of the respondents
wanted information about labour prior to their experience. It is important
that Nigerian women are allowed the benefit of social support during
childbirth, particularly as there is a lack of one-to-one nursing care and other
critical services, including epidural analgesia in labour, at many of the health
care facilities in Nigeria. Men could play a pivotal role in the process of
introducing support in labour so as to improve the outcome for both the
mother and her newborn.
Introduction
Labour forms the transitory phase between pregnancy and parenting, and is
characterized by fears and anxiety by both the woman (Rofe et al., 1993; Hofberg &
1
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2 I. O. Morhason-Bello et al.
Ward, 2003; Bastani et al., 2006) and her family members (Chapman, 2000). This
observation cuts across culture and race (Karauda et al., 2006; Todman, 2007).
Previous studies have shown that fears and a state of anxiety increase operative
intervention in labour (Sjogren, 1998) and adverse delivery outcomes (Sjogren, 1997;
Sieber et al., 2006).
Nigeria, with its population of about 140 million (NPC, 2006), currently lacks the
necessary resources for an efficient and effective maternal health care service
(Galadanci et al., 2007). The last National Demographic Health Survey showed that
about two-thirds of Nigerian women registered for antenatal care with about a third
delivering with skilled birth attendants (NDHS 2003). Of these, one-third – about
85% – patronized public hospitals, with the remainder using private health facilities
(NDHS 2003). The magnitude of this problem within Nigeria varies with region, with
the south having better care/facilities and the northern region having the worst. One
of the major reasons identified why women do not deliver in Nigerian health care
facilities is the poor attitude of health workers to their clients and poverty (Okafor,
2003). This issue is further compounded by the usual maternity policy of no patients’
relations being allowed at the bedside in labour rooms. Women therefore patronize
traditional birth attendants and mission homes, which offer all forms of reassurances
to pregnant women but with minimal or no obstetric care during labour (Okafor &
Rizzuto, 1994; Etuk et al., 1999).
Social/emotional support by companions has been shown to be beneficial to
women in labour irrespective of where it is practised (Hodnett & Osborn, 1989; Saisto
et al., 2001; Waldenstrom, 2004). The degree of the benefit varies with the type of
companion (Malestic, 1990; Ip, 2000a). Reduced perception of labour pain and
fear/anxiety, shorter duration of labour, and an overall feeling of a satisfying
childbirth experience are some of the identified benefits for women who had
companions during labour (Hofmeyr et al., 1991; Sjogren & Thomassen, 1997;
Waldenstrom, 2004).
In Nigeria, situated in sub-Saharan western Africa, many studies have reported
that women perceive pain in the same way as their colleagues in other parts of the
world (Olayemi, 2005; Kuti, 2006). It is therefore probable that levels of distress
during labour may be reduced if social support during labour is practised. Presently
in Nigeria, current public or government-owned hospital policies lack the incorpor-
ation of social support for a patient during the course of her labour, hence the basis
of this work. This study aims to document the attitude and preferences of pregnant
women about social/emotional support while in labour and also to seek factors that
may influence such attitudes.
Methods
This was a hospital-based cross-sectional study. Women attending antenatal clinic at
the University College Hospital, Ibadan (a government-owned tertiary institution in
south-western Nigeria) were recruited for the survey using systematic random
sampling. On each clinic day, a starting number between 1 and 10 was randomly
selected using a ballot and then every 10th woman was interviewed. This was
continued until the sample size was achieved. The instrument used for the study was
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Nigerian women’s attitudes to social support in labour 3
an open- and close-ended structured questionnaire. An initial pilot study was
conducted to validate the questionnaire at a separate health facility. The pilot
revealed the need to define specifically the types of support desired by respondents to
the research assistants so as to have a uniform interpretation of the result. The
identified types of support from the pilot were spiritual, errand, physical and
emotional.
Spiritual support included reassurance through faith in God’s protection and
promises of safe delivery, repeated traditional verses such as ‘the goat delivers
effortlessly without a midwife and the sheep never requires the intervention of a
health worker, you too [i.e. the patient by her name] will deliver with ease’, constant
reiteration of intercessionary prayers that use Biblical or Quranic memory verses etc.
‘Errand’ refers to support in the form of attending to payment of bills in tranches
and purchase of needed materials as may be prescribed by health workers. It may also
include calling the attention of the on-duty health workers, making contact with other
family members and the denominational clergy or Imam (Muslim clergy) or even
familiar personnel (especially senior physicians or midwives) within the facility.
Physical reasons include massage of the woman’s back, assisting in changing position
and holding hands during childbirth.
Emotional support includes the use of constant words of encouragement and
comfort, assurances that the childbirth process will be trouble-free and just the sense
of security that someone familiar is around them.
The questionnaire was then administered to the consenting antenatal patients. The
information obtained included their socio-demographic characteristics, past obstetric
history and views on social support in labour. The data were collated from August
to November 2006.
Statistical analysis was performed using SPSS 11 software. Bivariate analysis was
done using 
2 test while multivariate analysis was performed using logistic regression
and the level of statistical significance was set at p<0·05 (or 95% confidence level).
Results
Two hundred and twenty-four women were studied between the ages of 18 and 44
years with a mean age of 31 years (SD=4·27 years). Approximately half of the women
were between 30 and 34 years. Pertaining to occupation, professionals constituted
about 28%, followed by teachers (17%), traders (15·2%) and artisans (11·2%) (Table
1). Three-quarters had tertiary education while 21% had secondary school education
as the highest level of education. The predominant religion was Christianity (76·8%).
Primigravid women constituted about 37% of the respondents. Additionally, there
were equal proportions of those who had two and three pregnancies while about 21%
have four or more pregnancies. They were largely nulliparous (45·4%). Most of the
respondents had no history of abortion or miscarriage (Table 1).
Concerning preferences for social support, about 75% of these antenatal patients
wanted someone to be present to offer social support during their labour. Nearly 86%
of these women preferred their husband, while 7% and 5% respectively wanted their
mothers and siblings (Fig. 1).
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4 I. O. Morhason-Bello et al.
Table 1. Univariate distribution of patient’s socio-demographic characteristics
Variable Frequency Percentage
Age (years)
15–24 13 5·9
25–29 59 26·7
30–34 108 48·9
>34 41 18·6
Occupation
Housewife 21 9·4
Artisan 25 11·2
Civil servant 23 10·3
Teaching 38 17·0
Professional 63 28·1
Trading 34 15·2
Student 20 8·9
Educational level
Primary 10 4·5
Secondary 47 21·2
Tertiary 165 74·3
Religion
Christianity 172 76·8
Islam 51 22·8
Gravidity
1 83 37·1
2 42 18·8
3 43 19·2
R4 48 21·5
Parity
None 98 45·4
1 56 25·9
2 38 17·6
>3 24 11·1
Abortion/miscarriages
None 160 75·1
1 29 13·6
2 24 11·3
The main rationale for desiring social support during labour was discovered to be
emotional support (80·2%). Others included: spiritual (17·9%), errands (8·6%) and
physical activity (6·8%) (Fig. 2). About 67% would be happy if their relations were
allowed to be by their side during labour, while around 58% indicated their desire to
visit the labour ward before delivery. Three-quarters of the women felt information
materials/leaflets describing labour would be helpful prior to the actual experience and
about 69% expressed their willingness to pay additional charges for social care in
labour (data not shown).
Education (p=0·049), religion (p=0·025) and occupation (p=0·005) were signifi-
cantly associated with desire for a doula. Also significant were gravidity (p=0·004)
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Nigerian women’s attitudes to social support in labour 5
Fig. 1. Preference for social support during labour.
Fig. 2. Reasons for requesting social support (a doula) during labour.
and parity (0·003) (Table 2). Age and previous abortion or miscarriage were, however,
not significant (not shown).
The variables significant at the 10% level of significance were further subjected to
logistic regression analysis to adjust for possible confounding. Nulliparous women
were significantly more likely to desire social support in labour compared with other
parity groups (OR 3·57, 95% CI 1·49–8·52). Also, professionals were more likely to
desire social support compared with other occupational groups (OR 3·11, 95% CI
1·22–7·94) (Table 2). Women of other ethnic groups were also more likely to desire
social support compared with the predominant Yoruba ethnic group (OR 2·90, 95%
CI 1·02–8·26). Education, gravidity and religion were not significant.
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6 I. O. Morhason-Bello et al.
Table 2. Bivariate and logistic regression analysis of desire for social support by
patients’ characteristics
Bivariate Multivariate
Characteristic % desiring support (n) p OR 95% CI OR
Education
Tertiary 78·7 (164) 0·049* 1·21 0·56–2·59
vs %secondary 65·5 (55)
Religion
Christianity 78·9 (171) 0·025* 1·64 0·77–3·45
vs Islam 63·3 (49)
Occupation
Professional 88·7 (62) 0·005* 3·11 1·22–7·94*
vs Other 70·4 (159)
Tribe
Other 87·5 (40) 0·052 2·90 1·02–8·26*
vs Yoruba 72·9 (181)
Gravidity
1 85·4 (82) 0·004* 1·86 0·82–4·24
vs 2+ 67·9 (131)
Parity
Nulliparous 84·4 (96) 0·003* 3·57 1·49–8·52*
vs parous 66·7 (117)
*Significant at 5% level.
Choice of individual to act as support was significantly related to education
(p=0·003), age (p=0·040) and occupation (p=0·028) on bivariate analysis. Women of
higher ages, higher education and professionals preferred husbands as doula (Table
3). Religion, gravidity and previous abortion were not significantly related (not
shown). Higher education was significantly associated with preference for husbands as
doula (OR=2·96, 95% CI 1·08–8·11) on logistic regression (Table 3).
Concerning willingness to pay for social support, demographic characteristics,
gravidity or previous abortion were not significantly associated (data not shown).
Discussion
A positive childbirth experience is usually seen as the end-point of a successful
parturition (Crowe & von Baeyer, 1989). Studies have shown that knowledge of
parturients and their suggestions on ways of achieving an uncomplicated childbearing
process are associated with positive outcomes in labour (Crowe & von Baeyer, 1989,
Elcioglu et al., 2006). Social/emotional support during labour is one of the
interventions that has been employed to achieve positive childbirth experiences in
many settings (Hodnett & Osborn, 1989; Hofmeyr et al., 1991).
Preference for support in labour among the majority of Nigerian parturients in
this study is in tandem with their peers from other countries. This desire for social
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Nigerian women’s attitudes to social support in labour 7
Table 3. Bivariate and logistic regression analysis of preferred doula type (husband vs
other) by socio-demographic characteristics
Bivariate Multivariate
Characteristic % preferring husband (n) p OR 95% CI OR
Education
Tertiary 90·0 (130) 0·003* 2·96 1·08–8·11*
vs %secondary 70·3 (37)
Age group (years)
R30 89·4 (113) 0·040* 2·19 0·88–5·44
vs<30 77·4 (53)
Occupation
Professional 94·5 (55) 0·028* 1·74 0·50–6·02
vs Other 82·3 (113)
*Significant at 5% level.
support was found to be more among professionals and primigravid women.
Christianity appeared to be a significant factor influencing desire for social support;
however, on the logistic regression analysis model, it was no longer significant,
probably due to the confounding factor that more professionals were Christians. All
these findings were at variance with many Nigerian hospital policies where women in
labour are barred from having relations by their side. Although there is no study from
Nigeria yet on the labour outcome among women that have had support, the findings
of this study need to be subjected to large multicentred research with the intention of
determining its relevance during parturition in the Nigerian environment.
It is probable that the liberal disposition of private health care services in Nigeria
forms a major attraction for women who – though they receive antenatal care at
public health centres – tend to deliver in private and faith-based maternity homes
(NDHS 2003).
Most respondents preferred their husband to be their doula. This preference was
found to be significant among women with the following characteristics: professionals,
tertiary education and above the age of 25 years. Higher educational status (at least
above secondary level) was found to be more statistically significant than others on
further analysis. Generally, women in the higher social class (higher educational level)
tend to practise monogamy and hence the likelihood of their preference for their
husband. Although the presence of the woman’s partner as a companion is associated
with a better labour outcome in some settings (Ip, 2000b), the overall available
evidence suggests that – in general – female doula are associated with a better labour
outcome, when compared to others such as husbands, midwives and monitrice. This
is a challenge to the men folk, especially in a country where men do not normally
participate fully in the health care of their spouse. Therefore, the question of whether
Nigerian husbands are ready to be their spouse’s doula/companion in labour remains
unresolved.
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8 I. O. Morhason-Bello et al.
The reasons given by those who desired support were similar to those mentioned
in earlier studies, except ‘errand’. This may be a reflection of the level of education
among the study population, and more so, that none of the respondents had ever
experienced social support in labour. The identified predictors of those desiring
support were at least secondary education, professionals and nulliparity. These were
the same categories of Nigerian parturients identified by Olayemi et al. (2005) with
higher pain score in labour. It is advisable to allow such women the benefit of support
because many health care delivery facilities in Nigeria cannot afford enough midwives
to provide social support to parturients. It is not unusual to find a midwife on duty
in the labour ward suite with more than two women in labour at a time.
Another interesting finding of this study was that parturients from other ethnic
groups are more likely to demand social support in labour. This observation reflects
the views of earlier studies that showed that women who deliver in an environment
where the care-giver shares the same cultural background with her generally have a
more pleasant childbirthing experience (Olayemi, 2005). It is therefore understandable
why women from other ethnic groups would wish to have someone known to them
by their side during labour.
Although more than half of women interviewed were willing to pay for social
support, none of the factors considered were found to influence this decision. This
decision may encourage the hospital management to introduce the social support
programme especially for women who have no relations around.
Another important finding from this study was that more than half of the
respondents were willing to seek information about labour events, such as a prior visit
to the labour ward, a guided tour of the available medical facilities and as well as
information leaflets. Receiving qualitative information about childbirth during the
prenatal period has been found to reduce the anxiety level of parturients, reduce
labour pain perception and is associated with a more pleasant labour experience
(Heaman et al., 1992; Lang et al., 2006). Therefore, there is a need to make available
information leaflets for antenatal patients, as this will enable them to gain more
knowledge about labour events and also serve as educational materials for their
spouses and other family members.
In conclusion, this study revealed that Nigerian parturients desire social support
during childbirth. It is therefore imperative for health care-givers to pursue this issue
and determine whether the presence of companions will positively influence labour
outcomes in Nigeria through further operations research. The challenges that religious
values in a large heterogeneous population may throw up in the process should be
critically resolved, and these include diverse interpretation and myths as regards
specific meaning of issues surrounding childbirth in Nigeria (Etuk et al., 1999; Okafor,
2000). In addition, men should be included in the process of investigating the
relevance of this topical issue.
Acknowledgment
This study received grant support from the Gates Institute, Johns Hopkins University,
Baltimore, USA, through the Center for Population and Reproductive Health,
College of Medicine, University of Ibadan, Nigeria.
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Nigerian women’s attitudes to social support in labour 9
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