ANTENATAL WOMEN’S CHILDBEARING PRACTICES AT THE NIGER DELTA UNIVERSITY TEACHING HOSPITAL, OKOLOBIRI NIGERIA

Addah AO*, Unachukwu CE

Department of Obstetrics and Gynecology, Niger Delta University, Okolobiri, Nigeria

*Correspondence: Dr. Abednigo Ojanerohan Addah; +2348033417768; draddah@yahoo.com

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Abstract

Background: Overpopulation in a community or a country reflects high fertility desires of its citizens. A country can only progress meaningfully if its resources and amenities can provide for all its citizens.

Objectives: To examine the childbearing practices of antenatal attendees at the Niger Delta University Teaching Hospital, Okolobiri, Nigeria and whether there is any suggestion of fertility decline or transition.

Materials and Methods: A cross-sectional study of two hundred and fifty-two women who had antenatal care in the hospital during the study period. Data was collected using a structured self-administered questionnaire with a reliability coefficient of 0.85. Data collected were analysed using IBM SPSS Statistics version 25. Statistical significance was a p-value <0.05.

Results: The mean age of the respondents was 30.5 ± 5.9 years. More than half (53.6%) had tertiary education and 39.3% had secondary education. Only 29.4% were housewives/unemployed. The median parity was 2 and 229 women accounted for previous deliveries of 596 babies. The median desired total number of children was 4 (range 1 to 8). More than half (56.3%) did not believe in spacing after the first child. Seventy-six (30.2%) had no knowledge of modern contraceptives. There was a significant relationship (p – 0.018) between child sex preference and number of births.

Conclusion: With a current median parity of two children/woman and desired total number of children of a median of four children/woman, the childbearing practices of the population studied may not result in a fertility rate far below the Nigeria national average of 5.3 children per woman. Nevertheless, a study to derive the total fertility rate in the study population is necessary to determine whether or not there is ongoing fertility transition.

Keywords: Antenatal women, Childbearing practices, Modern contraceptive use, Child sex preference, Child spacing.

Cite this article: Addah AO, Unachukwu CE. Antenatal women’s childbearing practices at the Niger Delta University Teaching Hospital, Okolobiri Nigeria. Yen Med J. 2023;5(1):30–42.

INTRODUCTION

Large families are reminiscent of African societies because of their love for children and because polygamy is still widely practiced worldwide.1,2 When this happens, all the wives of one man would like to have children they call their own. Having many wives in a polygamous family transcends into a childbearing competition among the women in the Marriage.3 Discussing fertility desires and consequently overpopulation as it happens in Nigeria, other factors come into play like culture of the people. Most African cultures do not welcome contraception readily as they show many negative attitudes and sigma towards its use. Due to this cultural aversion to contraceptive use, there is low uptake of contraception in this world sub-region and, consequently, high fertility rates.4,5

Other issues related to fertility rate are the high prevalence of teenage pregnancies as it occurs in some sub-Saharan African countries. African cultures and religious faith Churches in this region do not accept teenage contraception readily for their family and Church members respectively.6 Disallowing adolescent girls who are sexually active from contraceptive use (an unmet need) may in the long run lead to teenage births at a tender age.7 After the conclusion of the pregnancy, the teenage girl would like to marry and start a new childbearing career. All these together mean that teenage girls would have more time for childbearing and consequently more children in their families.6,7

Another issue of fertility dynamics in the sub-Saharan African sub-region is the issue of separation, divorce, and remarriage, which are rampant in the-sub-region. However, when a woman passes through any of these marriage characterizations, they will have fewer children than those in intact marriages.

Overpopulation in a community or a country reflects the high fertility desires of its citizens. These events are also associated with the level of well-organized family planning programs in society and the extent of individual participation in these activities. A country can only progress meaningfully if its resources and amenities can provide for all its citizens. This study was aimed to examine the childbearing practices of antenatal attendees at the Niger Delta University Teaching Hospital (NDUTH), Okolobiri, Nigeria and whether there is any suggestion of fertility decline or transition.

METHODOLOGY

Study Design and Setting

The study was a cross-sectional descriptive study of the childbearing practices of two hundred and fifty-two antenatal patients at the NDUTH, Okolobiri, Nigeria. The NDUTH is in Bayelsa State Nigeria, it is the only Bayelsa state-owned tertiary health facility and is about 28 kilometers from the centre of the state capital Yenagoa. Despite being one of the states in the oil-rich Niger Delta and hosting major crude oil deposits and multinational rig infrastructure, Bayelsa State economic activities is still largely driven by commercial fishing owing to the abundant creeks; lagoons; rivers and swamps, subsistent farming and the civil service.9

 Study Population and Eligibility Criteria

Women attending the antenatal clinic at the NDUTH, Okolobiri, Nigeria participated in the study. There were no exclusion criteria except those who declined to participate.

  Sampling and Data Collection

The study was conducted for one month during which pre-formed questionnaires were distributed by convenience sampling to consenting antenatal attendees. Data obtained include age, marital status, age at first marriage, level of contraceptive awareness and use, and the number of children born and alive. The questionnaire was first pretested among 20 respondents and returned to the research team. Revised questionnaires were then finally administered to study participants. It was a self-administered questionnaire and supervised by residents in the department of Obstetrics and Gynecology of Niger Delta University, Amassoma.

 Data Analysis

The data collected were entered into a spreadsheet and cleaned for easy analysis, it was then transferred to IBM SPSS Statistics version 25 for analysis. Results were summarized using frequencies, percentages, mean, standard deviation, median, range and presented in tables and plots. Statistical significance was a p-value <0.05.

RESULTS

Sociodemographic Characteristics of Women In the Study

Two hundred and fifty-two women participated in the study. Seventy-three (29.0%) were aged 30 – 34 years, while 71 women were 25 – 29 years. The average age of respondents was 30.5 ± 5.9 years, while the average age at first marriage and at first delivery was 26.8 ± 5.9 years and 25.8 ± 4.6 years, respectively (Table 1). Greater than half of the women had a tertiary level of education (53.6%), belonged to the Pentecostal Christian religious sect (58.2%), and were of the Ijaw ethnic nationality (51.2%). The majority were married (80.6%), 22 women (8.7%) were single women who had never married. Eighteen women (7.1%) had remarried after their first marriage, however, there were nine women (3.6%) who were separated from their husbands and were still unmarried (Table 1). About 3 in every 10 women in the study were either unemployed/housewives (29.4%) or professionals like doctors, nurses, pharmacists, teachers, etc. (29.8%).

Child Sex Preference Among Women In the Study

Figure 1 showed that about a third of the women showed no sex preference (32.9%), male sex preference (32.6%), and female sex preference (34.5%).

Characteristics Reflecting Fertility Desire Among Women In the Study

Twenty-three women (9.1%) had their first birth experience as teenagers, and as high as 47 women (18.7%) had children before their first wedlock (Table 2). One hundred and twenty-nine women (56.3%) did not believe in child spacing after their first babies, while only 190 women (83.0%) indicated they practiced exclusive breastfeeding for their babies (Table 2).

Seventy-six women (30.2%) indicated they had no knowledge of modern contraceptives methods, 99 women (39.3%) construed the use of traditional contraceptive methods as using modern contraceptive methods, and meanwhile, only 77 women (30.6%) had knowledge of modern contraceptive methods in family planning. Furthermore, Table 2 showed that 145 women (57.5%) were aware of places where family planning services can be accessed. Only about 1 out of every 5 women (21.8%) practiced/used modern family planning methods among the women in the study.

As presented in Figure 2, of the 77 women, who knew of modern contraceptive methods, the commonest known method was the use of male condoms (93.5%). Other methods include coils (61.0%), levonorgestrel (45.5%), and contraceptive pills (36.4%).

Indicators of Fertility Rate of Women In the Study

Table 3 showed the median parity among the 252 women was 2, ranging between 0 and 7. The total number of babies born by 229 women (90.9% of the subject population) who had previously delivered was 593 babies; 575 babies of the 593 babies (96.9%) were alive while 18 babies (3.1%) from 13 women in the study were dead, giving a mortality rate of 30.4 babies per 1000 live birth (Table 3). One hundred and eighty-four women (73.1%) had an average of 2 children (Range: 0 – 6) with their current husbands. Total number of babies delivered by 47 women (18.7%) before wedlock was 87 babies (14.7%). Averagely, women in the study desired to have a median of 4 children with a range between 1 and 8 children. When the women achieve their desires, the 252 women in the study would have delivered 1,065 babies (Table 3).

Relationship Between Maternal Characteristics and the Number of Children Alive Among Women In the Study

Women who had their first delivery between the age of 15 – 19 years had a median number of 2 children (range 1 – 5). Women who had their first delivery between the ages of 20 – 24 years, 25 – 29, years, and 30 – 34 years also had a median of 2 children but the range was between 1 and 7 children (Table 4). Women who had first birth at 35 years and above had 1 child as the median number of children alive, ranging between 1 and 4. This show that the age of first delivery did not significantly influence the number of children alive for women in the study. Age of women at first marriage was also not significantly related (Kruskal-Wallis ꭓ2 = 2.54; p – 0.638) to the number of children alive with the women. The marital status of the women (Kruskal-Wallis ꭓ2 = 11.49; p – 0.009), having children before marriage (U-test = 2191.5; p – 0.001), and parity (Kruskal-Wallis ꭓ2 = 155.46; p – 0.001) affected number of living children significantly (Table 4). Women who had children before marriage had a higher median number of children alive (median: 3; range 1 – 7 vs median: 2; range 1 – 5). Figure 3 also shows that the number of children the women desired to have also directly relates to number of children alive for each woman (ɼ = 0.48; p – 0.001).

Relationship Between Sex Preference and the Number of Children

Table 5 shows that there was a significant relationship (ꭓ2 = 5.60; 0.018) between sex preference among women and the number of babies born to the women. Male preference showed a significant relationship with the number of children in the households (ꭓ2 = 4.69; 0.030). Female preference was however not significantly related to number of children in the household (ꭓ2 = 3.58; 0.0.465). Table 4 showed that among women with sex preference, 59.6% of the women were with 1 child, while 85.2% of women with 5 – 7 children expressed a desire for sex preference. The propensity to have many children increases among women with sex preferences, especially among those with male sex preferences (Table 5).

 Relationship Between Modern Contraceptive Methods Use And Access To Family Planning Service, Knowledge of Modern Contraceptive Methods, Sex Preference

In Table 6, the use of modern contraceptive methods was significantly associated with knowing where family planning services could be accessed (ꭓ2 = 19.61; 0.001). Those who know where modern contraceptive services could be accessed were 5 times more likely to use modern contraceptives methods than those who do not know (OR – 5.06; p – 0.001). The knowledge of modern contraceptive methods and sex preference among the participating women were not significantly associated (p > 0.05) with the use of modern contraceptive methods in this study.

Reasons For Stopping Family Planning

The fifty-five women who used modern contraceptive methods in this study have had to stop the use at different times in the past. The reason for stopping include affectation of the regular menstrual period of the women (40.0%), and desires to have another baby (29.1%). Other reasons include difficulty with daily compliance with taking the drugs (7.3%) and pimples associated with the some of the methods (7.3%).

Table 1: Sociodemographic characteristics of women in the study

Characteristics

Frequency N = 252

Percent (%)

Age

  

20 – 24 years

41

16.3

25 – 29 years

71

28.2

30 – 34 years

73

29.0

35 – 39 years

45

17.9

>40 years

22

8.7

Age of respondents in years – Mean ± SD

30.5 ± 5.9

Age at first marriage in years – Mean ± SD

26.8 ± 5.9

Age at first birth in years – Mean ± SD

25.8 ± 4.6

Religion

  

Pentecostal

147

58.2

Anglican

55

21.8

Catholic

32

12.8

Jehovah witness

14

5.6

Islam

4

1.6

Education

  

No formal education

6

2.4

Primary

12

4.8

Secondary

99

39.3

Tertiary

135

53.6

Tribe

  

Ijaw

129

51.2

Igbo

65

25.8

Yoruba

20

7.9

Urhobo

18

7.1

Calabar

11

4.4

Hausa

9

3.6

Occupation

  

Civil servant

23

9.1

Petty trader

31

12.3

Businesswoman

49

19.4

Housewife/ Unemployed

74

29.4

Professionala

75

29.8

Marital Status

  

Married

203

80.6

Single

22

8.7

Re-married

18

7.1

Separated

9

3.6

aProfessionals included Nurses, Doctors, Teachers, ICT engineers

Figure 1: Sex preference among the women in the study

Table 2: Characteristics reflecting fertility desire among women in the study

 

Characteristics

Frequency N = 252

Percent (%)

 

Pregnant as a teenager

 

 

Yes

23

9.1

 

No

229

90.9

 

   

 

Had children before Marriage

  

 

Yes

47

18.7

 

No

205

81.3

 

   

 

Child Spacing

N = 229

 

 

No Child Spacing

129

56.3

 

One year

61

26.6

 

Two years

39

17.0

 

   

 

Breastfeeding

N = 229

 

 

Exclusive breastfeeding

190

83.0

 

Mixed breast and cow milk

39

17.0

 

   

 

Family Planning Knowledge

  

 

No family planning knowledge

76

30.2

 

Knowledge of traditional contraceptive methods

99

39.3

 

Knowledge of modern Contraceptive methods

77

30.6

 

   

 

Know where to access Family Planning

  

 

Yes

145

57.5

 

No

107

42.5

 

   

 

Practice Modern Family Planning methods

  

 

Yes

55

21.8

 

No

197

78.2

     

Figure 2: Knowledge of modern contraceptives among the women in the study

Table 3: Fertility desire indices among women in the study

Characteristics

Number of Women Involved N (%)

Count

Median (Range)

Sum

Parity

252 (100.0)

2 (0 – 7)

 

Live births

229 (90.9)

2 (1 – 8)

593

Child(ren) alive

216 (85.7)

2 (1 – 7)

575

Dead child(ren)

13 (5.1)

1 (1 – 2)

18

Child(ren) for present husband

184 (73.1)

2 (0 – 6)

452

Child(ren) before marriage

47 (18.7)

2 (1 – 3)

87

Number of Children desired

252 (100.0)

4 (1 – 8)

1065

Infant mortality rate

18/593 x 1000

 

30.4 per 1000 birth

 

Table 4: Relationship between maternal characteristics and number of children alive among women in the study

 

Characteristics

Frequency

N = 229 (%)

Number of children – Median (Range)

Test Statistic (pValue)

 

Maternal age at first birth

   

 

15 – 19 years

23 (10.0)

2 (1 – 5)

2.54a (0.638)

 

20 – 24 years

39 (27.1)

2 (1 – 7)

 

 

25 – 29 years

89 (38.9)

2 (1 – 7)

 

 

30 – 34 years

68 (29.7)

2 (1 – 7)

 

 

≥ 35 years

10 (4.4)

1 (1 – 4)

 

 

Marital status

   

 

Single

7 (3.1)

1 (1 – 2)

11.49a (0.009*)

 

Married

195 (85.2)

2 (1 – 7)

 

 

Separated

9 (3.9)

2 (1 – 4)

 

 

Re-married

18 (7.8)

3 (2 – 4)

 

 

Maternal age at first marriage N = 222

  

 

15 – 19 years

17 (7.6)

3 (1 – 5)

3.36a (0.500)

 

20 – 24 years

51 (23.0)

3 (1 – 7)

 

 

25 – 29 years

77 (34.7)

2 (1 – 5)

 

 

30 – 34 years

75 (33.7)

2 (1 – 7)

 

 

> 35 years

2 (1.0)

2 (1 – 2)

 

 

Women had children before marriage

  

 

Yes

47 (20.5)

3 (1 – 7)

2191.5b (0.001*)

 

No

182 (79.5)

2 (1 – 5)

 

 

Parity

N = 227

  

 

Primiparous

49 (21.6)

1 (1 – 2)

155.46a (0.001*)

 

Multiparous

154 (67.8)

2 (1 – 4)

 

 

Grand multiparous

24 (10.6)

5 (3 – 7)

 

aKruskal-Wallis, b U-test, *Statistically Significant

Figure 3: Relationship between the number of children alive and the total number of children a woman desires.

Table 5: Relationship between Sex preference and number of children

 

Characteristics

 

Sex Preference

Chi-square test (pValue)

 

 

 

Yes

N = 148 (%)

No

 N = 69 (%)

 

Number of children

    

 

1 Child

47

28 (59.6)

19 (40.0)

5.60 (0.018*)

 

2 Children

81

53 (65.4)

28 (34.6)

 

3 Children

39

27 (69.2)

12 (30.8)

 

 

4 Children

23

17 (73.9)

6 (26.1)

 

 

5 – 7 Children

27

23 (85.2)

4 (14.8)

 

 

 

 

Male sex preference

 

 

 

 

Yes

N = 74 (%)

No

143 (%)

 

 

1 Child

47

16 (34.0)

31 (66.0)

4.69 (0.030*)

 

2 Children

81

21 (25.9)

60 (74.1)

 

3 Children

39

12 (30.8)

27 (69.2)

 

 

4 Children

23

11 (47.8)

12 (52.2)

 

 

5 – 7 Children

27

14 (51.9)

13 (48.1)

 

 

 

 

Female sex preference

 

 

 

 

Yes

N = 74 (%)

No

N = 143 (%)

 

 

1 Child

47

12 (25.5)

35 (74.5)

3.58 (0.465)

 

2 Children

81

32 (39.5)

49 (60.5)

 

3 Children

39

15 (38.5)

24 (61.5)

 

 

4 Children

23

6 (26.1)

17 (73.9)

 

 

5 – 7 Children

27

9 (33.3)

18 (66.7)

 

*Statistically Significant

Table 6: Relationship between Modern Contraceptive Use and Access to Family planning service, knowledge of modern contraceptive methods, sex preference among women I the study

Characteristics

Modern Contraceptive Use

2

(pValue)

Odd ratio (95%CI)

pValue

 

Yes

 N = 55 (%)

No

N = 197 (%)

 

Know where to access Family Planning

   

Yes

46 (31.7)

99 (68.3)

19.61 (0.001)

5.06 (2.35 – 10.89)

0.001*

No

9 (8.4)

98 (91.6)

1

 

 

     

Knowledge of Modern Contraceptive Use

   

Knowledgeable

21 (27.3)

56 (72.7)

1.93 (0.165)

1.56 (0.82 – 2.91)

0.167

Not knowledgeable

34 (19.4)

141 (80.6)

1

 
      

Sex Preference

     

Present

36 (21.3)

133 (78.7)

0.08 (0.774)

0.92 (0.58 – 1.71)

0.774

Absent

19 (22.9)

64 (77.1)

1

 

 

     

Male Preference

     

Present

17 (20.7)

65 (79.3)

0.09 (0.770)

0.91 (0.48 – 1.73)

0.770

Absent

38 (22.4)

132 (77.6)

1

 

 

     

Female preference

    

Present

19 (21.8)

68 (78.2)

0.01 (0.997)

1.00 (0.53 – 1.88)

0.997

Absent

36 (21.8)

129 (78.2)

1

 

*Statistically Significant

Table 7: Reasons for stopping family planning

 

Reasons

Frequency

N = 55

Percent

(%)

 

The drug makes me to see my period many times

22

40.0

 

I want to have another baby

16

29.1

 

Difficulty taking the drug everyday

4

7.3

 

The drug makes to get pimples

4

7.3

 

Does not protect against genital infection

3

5.5

 

The drug makes me to spot

3

5.5

 

I had breast pathology

2

3.6

 

My husband does not like the drug.

1

1.8

DISCUSSION

Fertility control to the barest minimum number of children per woman of reproductive age (or fertility transition) reflects many factors acting in unison, like well-organized family planning programs, desire for small family size, female education, family income, the age of the would-be mother and other factors studied that add up to these enormous benefits to the wellbeing of the woman, community and nation at large.

The mean age of the cohort of antenatal women in this study was 30.5 years. This agrees with Nigeria National Demographic and Health Survey of 2018 where the mean age of the antenatal women in the survey was 30.5 years.10 The benefit of this result to the would-be mother is that her anatomical development potential is complete for childbearing as compared to the teenage girl in pregnancy who is more likely to experience obstetric complications like obstructed labor from aforesaid.10,11

Greater than half of our subjects in the study had tertiary education. The educated woman is more likely to embrace family planning and assimilate antenatal health care teachings including child survival procedures. Avoiding the death of the born child may in the long run lead to a reduction in the total fertility rate. A team of Ghanaian author’s did a study on child survival and the role played by mothers’ education and their results showed that a woman with tertiary education child has 22% fewer chances of dying compared to women with less educational status.12 

Eighty-one percent of our study subjects were married as against 7.1% who remarried. From evidence-based studies, it is known that women who remarried are more likely to have fewer children than those in marriage. This may be so, as the former waste reproductive time looking for a new partner to marry.8

In our study, we examined the issue of sex preference among the studied subjects: if they would like to have a particular sex before terminating childbearing. Our results showed that having a male or a female child was not significantly associated to stopping childbearing.

Our results differ from a study in Nepal where they place much emphasis on having a male child. Their results showed that their sex ratio was male to female at 1.41.13

Sex preferences cut across cultures, and sub-regions as some families place much value on having a particular sex, especially the male gender. However, sex selection in the natural conception cycle is a chance game. In attempts to achieve this objective, concerned women carry one pregnancy after the other looking for a particular sex and in that process increasing their total fertility rate.14

In our study, 81 percent of the women in the study were married and were 12 times more likely to have a higher fertility rate compared to single or unmarried women. This result is similar to another study on the subject in Germany where women who remarried have fewer children than women with intact marriages because of the time lost looking for a partner, stressing the relationship of marriage to higher fertility.8

The median fertility rate for women in our study was 2 children/woman. This is similar to the total fertility rate in the United Kingdom, a developed country with a fertility transition where their total fertility rate was 1.56 children /woman. However, it must be stressed that the United Kingdom reports were on the children a woman may have in her lifetime, our study was done on pregnant women who after delivery may embark on another pregnancy.15

In our study there was a significant relationship between sexual preference among women and the number of children, male children showed a significant relationship with the number of children In the household.  The propensity to have more children increases in women with sex preference.

All our findings in our study were similar to a study on sex preference in Malawi except for the exception that the women in their study preferred female children.16          

The results of our study showed that maternal characteristics like age at first marriage, age at first childbirth, marital status, women who had children before marriage (non-marital fertility), and parity were all significantly associated with the number of children alive among women in the study and indirectly the fertility rate.    A study done in the USA on non-marital fertility in Nigeria showed that though the level of non-marital fertility is low in Nigeria, it has risen over time and in 2018 the level was 42.1%.17

In this study, knowledge of modern contraceptive methods was not significantly associated with its use. However, knowledge of where to access them had a significant association with use. The result in this study was different from another study done in Kano Nigeria where the respondents had a good knowledge, attitude and use of modern contraceptive methods.18 Overwhelming majority of the respondents were married and the majority had tertiary education, unlike only a third of the Kano group with tertiary education. The differences may have been due to some yet unknown reasons for contraceptive use and may call for another study of knowledge and attitude in South-South Nigeria where our study was done. 

The prevalence of modern contraceptive use among the studied respondents was 22%, higher than the 17% of married women that used modern contraceptive approaches by national average.10

Exclusive breastfeeding and child spacing are some of the child survival measures introduced by the United Nations Educational Fund for Children (UNICEF) and World Health Organization (WHO) for poor and middle economies including the sub-Saharan Africa region.19 In the study. when asked about the method of breastfeeding, 83% of subjects said breastfeeding was an option.

High-level desires for breastfeeding if put into practice and a high level of educational status of respondents all put together are some of the determinants of child survival and these may have played out in this study, as the infant mortality rate was 35.4 deaths/1000 children. The infant mortality rate among the study population is better than the National average which stood at 132 deaths/per 1000 children.10

WHO recommends 24 months intervals between childbirths with motives for the survival of previous children. When asked about child spacing in our study, only 17% of respondents agreed with WHO recommendation of 24 months birth intervals, more than half said they will not practice child spacing, while 29% said they will give birth yearly in variance with WHO recommendations.  

Respondents in the study who practiced the use of modern contraceptives, when asked why they stopped using the method type, the foremost reason given was that it makes them to see their periods many times in a month (meaning spotting or outright bleed). As previously said in this discussion, contraceptive uptake is a major requirement for fertility transition.

A limitation of this study is that it assessed previous childbirth and total fertility intentions of the antenatal attendees but did not assess their age-specific fertility rate, therefore, the total fertility rate of the study population could not be derived from this study.

 

CONCLUSION

With a current median parity of two children/woman and desired total number of children of a median of four children/woman, the childbearing practices of the population studied may not result in a fertility rate far below the Nigeria national average of 5.3 children per woman. Nevertheless, a study to derive the total fertility rate in the study population is necessary to determine whether or not there is ongoing fertility transition.

ACKNOWLEDGMENT

We acknowledge the statistician, Dr. Adesina Adedotun who carried out the statistical analysis for this study.

 

AUTHOR CONTRIBUTIONS

Author AAO conceptualized the study, designed the questionnaire and wrote the first draft of the manuscript. Author UCE supervised data collection, proofread the manuscript and made corrections. All authors read and approved the final draft.

 

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

 

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

 

ETHICAL APPROVAL

Ethical approval was obtained from the ethical committee of the Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State.

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