Usually, a combination of factors prevented women from having an institutional delivery. Economic barriers may have affected women in control areas more, and perceived quality of care in health posts may have affected women in intervention areas more – although these barriers usually interact with other factors and our sample was small. Women were unlikely to deliver their babies in a far away health facility, when it was dark and late and there was no one to carry them. If there is a chance that the health facility might be closed, they are even more unlikely to attempt the journey while in labour. If a woman’s privacy is not maintained, and she is not treated with respect, she won’t go to a health institution. The familial expectation that women can and should deliver at home exists in this context, and women and families were concerned about incurring costs that were often considered avoidable and unnecessary. Although the incentive was encouraging institutional deliveries, some study participants, felt that the incentive alone was not enough, and improvements in quality of care were also necessary.
Limitations
Our study has shown that the role of family members in increasing institutional deliveries is key, and our study would have been strengthened if we had collected data from this respondent group. We have tried to overcome this limitation by collecting data from men and women, and HFMCs in a concurrent study about quality of care in the same study areas [
28].
We only interviewed women who had had a normal delivery at home. If a delivery becomes complicated, the reasons for delays in the home may change. For example, the cost of delivery may become more of a concern if families feel that a complicated delivery is more costly than a normal delivery. Several national studies have focussed on care-seeking during complications, and if the goal is to create a national norm of institutional delivery it is also important to consider women having normal deliveries.
Aama programme
Many women were concerned about the costs of institutional deliveries, despite being aware of the Aama programme. A recent rapid assessment of the Aama programme also found high levels of awareness about the programme, but found that 23% of women were still paying some of the costs of their delivery [
29]. Another study in Makwanpur District reported that the incentive was perceived to be insufficient to fully cover delivery expenses, was not always received on time [
28]. To ensure proper management for the Aama programme, monitoring is necessary, and could be addressed by HFMCs within our intervention.
Quality of care
Our study indicates that perceived quality of care is one of the main issues that causes delays in the home. Although distance and transportation are also barriers to institutional delivery [
30], there is some evidence that quality is more important than distance to health facilities [
31]. Women in our study reported on the importance of good staff behaviour, privacy, and the availability of staff. These issues were given less importance by HFMCs and communities members in a concurrent study [
28]. If communities are unaware of the key issues that discourage women from delivering in health institutions, these issues will not be the focus of advocacy efforts. It is important that HFMC and community members actively seek the opinions of women of reproductive age to understand what affects women’s motivation to deliver in health institutions.
The aspects of quality that were discussed are amenable to change and could be targeted in our intervention to positively affect utilisation. We aim to stimulate a dialogue between women, HFMCs and communities, although we acknowledge that changes in attitudes and institutional cultures may take time [
32]. A recent study to improve quality of care in hospitals in Malawi suggests that staff stability, leadership, training, and ongoing support from district staff and external coaches trained in quality improvement methods are necessary to sustain the process [
33]. Generally, there is little evidence regarding how quality improvement initiatives can improve outcomes [
34‐
36]. It is important to understand how our intervention is or is not effective, and we will monitor quality of care as it could be an important driver of reduction in the first delay.
It has been suggested that a lack of awareness and education among women prevents institutional deliveries [
28,
37]. Literacy rates and educational achievement of women lag behind that of men, with women in the plains being particularly disadvantaged [
17]. Most of the women in our sample belonged to a Buddhist indigenous minority group, who are said to enjoy more freedom within the private sphere, and better access to and control over household resources than other Hindu women [
38,
39]. Yet in the public sphere these women are often excluded from participation due to caste, language or religious dominance of other groups [
27]. We found that despite their low educational attainment and social exclusion, many women in our study were aware that institutional delivery could be good for their health and their baby’s health. It appears that health promotion efforts and advice from health workers at antenatal care visits may be increasing awareness. We found that women’s status in the home, and the extent of family support, were more significant determinants of home delivery than awareness and education [
40], despite their relative ethnic autonomy in the home. Although some research supports these findings [
40], high profile studies like the NDHS [
4] and the Maternal Mortality and Morbidity study in 2008 [
41] may be misleading in their indication that family support is not a major barrier to institutional delivery. It is important to capture the complexity of factors affecting place of delivery, including the fact that women often put the desires of others before their own needs [
26]. The literature from the region also indicates that enduring childbirth without complaining or disturbing others is a source of pride [
42‐
44] and if any fuss is made it may be viewed as shameful and uncivilised [
45].
Our study indicates that knowledge about the health benefits of institutional delivery may not be sufficient to change behaviour. Women also need to be able to communicate that they are in labour, that they want to go to a health institution, and their family needs to be ready to respond immediately. Through our intervention we are targeting women, families, and communities, as we believe that this may be more successful than targeting women alone.