Spatial variation and hierarchical analysis of institutional delivery dropout after antenatal care contacts in Nigeria: findings from 3-survey rounds

Institutional delivery (ID) dropout (IDD) after antenatal care (ANC) contacts remains a threat to maternal and newborn survival, particularly in low resource sub–Saharan Africa. While literatures boom on ID and ANC, there is paucity of evidence on IDD. Thus, we investigated the prevalence, spatial patterns and individual and community predictors of IDD to inform maternal and child health program in Nigeria. Secondary analysis of pooled 3-rounds of Nigeria demographic and health survey (NDHS 2008, 2013 and 2018) were conducted in Stata and R. Rural–urban differences in IDD prevalence was quantified in frequency (percentage), spatial variation in IDD was examined via the geolocational composition while Rao-Scot and hierarchical analysis were performed to identify and predict the significance of the nested individual, household and neighborhood factors at 95% confidence interval (CI) respectively, with heterogeneity assessed via intra-cluster correlation. About 46.2% of women dropout of ID after ANC, with spatial pattern revealing highest (80.4%) and lowest (6.8%) IDD rate in in Sokoto (northwest) and Imo (southeast) respectively. Accordingly, odds of IDD is over 3 times more likely in northwest (AOR = 3.35, 95%CI = 2.76 – 4.04), and about 2 times less likely in the southeast (AOR = 0.65, 95%CI = 0.51 – 0.84) compared to northcentral. Having problem seeking medical care (AOR = 1.23, 95%CI = 1.05– 1.50) and long distance to health facility (AOR = 2.50, 95%CI = 2.32 – 2.68) increase the odds. Also, the odds decrease by wealth and increase by birth order. IDD after ANC exhibit marked spatial heterogeneity with significant north–south divides and was driven by Women autonomy and health facility access respectively. Advocating women health independence and community specific strategy to improve healthcare access is critical to achieve IDD reduction and optimal health.