Homebirth preference
Participants preferred homebirths due to normative perceptions, previous experience of homebirths, high costs of traveling to health facilities, and distance to such facilities. Participants who described homebirths as normative perceived such practice as existing as far back as they remembered. One young father [Farmer, 20 yrs., NR] preferred homebirths because he was born at home. An older father elaborated:
…we live in a village and because of that we always want our women, if not because of things beyond our control, to deliver at home… Yes we wish it [homebirths] very much, if it were so simple, we would have preferred that [Farmer, 60 yrs., NR].
This reflects homebirth preference as a norm in the village that spans generations, a view supported by several mothers as well.
Mothers who preferred home births also echoed the idea in the quote above that the ability to deliver at home is beyond a pregnant woman’s control. They noted that while they try to give birth at home, they are willing to accept “whatever God will give” them, since labor complications may result in them having to seek care at a health facility. Acknowledging the unpredictable nature of women’s labor experiences, health facility delivery care was considered a last resort, once it became clear that the attempt to deliver at home was not feasible.
Other mothers and fathers preferred homebirths based on past successful experiences with homebirths. For example, two fathers mentioned that they preferred homebirths because their wives’ previous births, from eight and six pregnancies respectively, were homebirths. Participants generally associated previous homebirths with relatively manageable birth experiences. For example, one mother with a homebirth preference explained:
When you deliver in the house, they will say your delivery wasn’t challenging…Some [women] when they are to deliver they have complication… some [women] too, when they feel pains, you will see that they walk a little, you see that they will just come and deliver [Farmer, 20 yr., NR].
This mother’s comments reflect the view of other mothers who, looking back on their previous birth experiences, associated homebirths with having an easy labor experience.
A number of participants alluded to costs associated with traveling to health facilities, as being reasons for preferring homebirths. In getting to such health facilities, pregnant women often had to endure traveling through poor road conditions. For example, a father (Farmer, 35 yrs., NR) who preferred homebirth delivery argued,
“The reason being that our roads are not good and so it is problematic to travel with them [pregnant women] on such roads, that is not good for their health.”
The combined effect of poor roads and use of an unsuitable but common means of transportation like motorcycles was considered detrimental to women’s health and was a reason to prefer delivering at home among both men and women.
Participants whose homebirth preference was due to concerns regarding distance and cost associated with facility-based care, tended to avoid health facility care until the onset of complications. Once women’s health conditions became critical, their relatives were forced to borrow motorcycles and pay for fuel, or pay for a vehicle to transport the women to a health facility. Some pregnant women had to be carried on bicycles and some walked to the facilities. A lack of birth preparedness or an emergency plan among participants provides a striking example of how homebirth preferences may have contributed to women’s experiences, including severe complications for women and babies and even neonatal death.
For instance, a mother with a preference for homebirths (Farmer, 20 yrs. NR) sought the assistance of a TBA during a prolonged labor. The mother was eventually sent to a health center to receive further birth assistance, as the TBA’s efforts were unsuccessful. She later mentioned, “The child died in my stomach before they even operated.” Her preference for home delivery delayed her seeking of facility care. We also observed three similar narratives of prolonged labor among women with a preference for homebirth. The women mentioned that they lost their newborns during birth, and some experienced postpartum illness. According to their narratives they spent substantial time attempting to achieve home birth delivery, by initially seeking the assistance of TBAs during labor, and relying on traditional medicine. Their use of health facilities was a last alternative for receiving treatment for complications once it became evident that homebirth was unachievable. The women’s experiences compounded the challenges in receiving care in facilities – e.g. distance, cost, and quality of care – and possibly contributed to their negative health outcomes.
Health facility birth preference
Participants who preferred health facility delivery expressed concerns about risks involved in homebirths, the need for skilled care for birth complications, and personal concerns about pregnant women’s health, as explanations for their preference. Additional reasons included previous experience of facility birth and the perceived high prevalence of, or a shift in norms towards, facility delivery in certain communities.
Certain participants preferred health facility births because of their awareness of health risks associated with childbirth. In one mother’s [Farmer, 30 yrs., NR] view, delivering at the clinic was safer, since she and her baby would receive care in case of any complications. A father with the same opinion maintained that he was mainly concerned with finding the right kind of health facility where his wife could experience safe delivery.
A few participants described personal health concerns that prompted their intentions to seek facility-based birth delivery. Notably, one mother explained, “Because I am not well, whatever happens, I will go to the hospital to give birth because I don’t know what will happen to me” [Farmer, 45 yrs., NR]. She experienced diarrhea and vomiting during pregnancy. She sought care at a health center and was then referred to a main hospital where she received the appropriate care for her ailment. This mother’s narrative parallels that of a young father (Farmer, 20 yrs., NR) who described his wife’s pregnancy experience as very concerning. According to him his wife had difficulties sleeping at night. Besides her regular attendance to the health facility for antenatal care, he had to “carry her to the hospital” a few times because of her illness. Consequently, to avoid labor complications, the father and his wife planned for her to deliver at a health facility.
Similar to the homebirth preference, health facility delivery preference for some participants was based on whether women’s previous pregnancies resulted in facility births. For instance, one mother (Hairdresser, 28 yrs., CR) preferred to give birth at her community’s health facility because her two children were born there. She expressed her satisfaction with the role played by health providers in assisting with her previous delivery:
The midwife here is good and she does not scream at people in labour. As you know, going to deliver is a very painful thing and some of the midwives scream or shout at pregnant woman in labour. [Hairdresser, 28 yrs.]
Several participants who utilized health centers staffed by helpful and caring midwives shared this mother’s sentiments about supportive care from the SBA. Some also noted that the midwives often accompanied pregnant women in labor to the referral hospital and made visits to the women’s home postpartum. This was not always the case, as other participants who preferred homebirths indicated that negligent SBAs staffed certain health centers. As evidence, one mother provided the following explanation:
I was also crying when I saw and heard my child crying. One of the nurses came to insult me that "what is the meaning of the tears that I am shedding over there?" I asked her why she was asking me the question; could she not see my child crying? She did not mind me but she just left the room [Occupation unknown, 34 yrs., CR].
The mother’s baby was crying because it was not being attended to, which caused her to cry too. Her experience with the nurse indicated that the nurse was both rude and unhelpful, as she refused to assist the mother with her crying child.
Two fathers perceived childbirth at the health facility in their community as a regular practice. According to them, it is expected that women would give birth at that facility. One of the fathers provided further insight into why community members were seeking facility skilled delivery:
She [his wife] always gives birth at the hospital. So, she was always going to hospital as scheduled for her during the pregnancy. Also, if one is pregnant and you do not go to the hospital, the staffs over there may refuse to take care of you when you go into labour [Farmer, 50 yrs., NR]
Community members like the participant’s wife sought antenatal care throughout their pregnancy term at their local health facility, in part because they perceived failure to do so may result in denial of care from SBA during labor.
The general narrative of participants who preferred facility births indicated that besides seeking health facility care for pregnancy/labor complications, women were overall likely to use facility care throughout their pregnancy experience. That is, their preference of facility delivery likely led them to access health facilities more frequently than participants who preferred homebirth. Despite having to overcome common barriers to seeking health services in rural settings, we found that almost all of the women successfully delivered their infants following referral to health facilities. The two exceptions were those who sought care at the same health center noted for being of poor quality and having uncaring staff members.
For example, a father (Famer, 37 yrs., CR) who preferred homebirth described his wife’s attempt to seek care at that facility when she was in labor as distressful. His account of this experience revealed that despite seeking care at the health center, her labor was prolonged. His wife was turned away and told to seek care at a hospital farther from their community because the health workers were attending a party. She subsequently experienced a stillbirth. The father’s narrative highlights the notion that besides one’s preference for and effort to achieve facility delivery, other factors related to delay in seeking care (e.g. lack of provider support) are beyond the control of an individual.
Ultimately, this group of participants’ birth location preference enabled them to decide on a plan for receiving care from a SBA once pregnant women went into labor. Generally, their birth narratives showed that the course of action for when a pregnant woman went into labor or experienced complications was to initially seek care at a health facility. Such initiative likely allowed them to avoid some of the dangers associated with prolonging needed care for labor complications at a health facility.