Factors influencing women’s preference for health facility deliveries in Jharkhand state, India: a cross sectional analysis

Reducing maternal mortality is a critical global priority. Efforts have resulted in a 47 % decline in global maternal deaths since 1990. Yet, globally an estimated 287,000 maternal deaths continue to occur every year [1]. In addition, 300 million women in the world suffer from long-term or short-term illness brought on by pregnancy or childbirth [2]. One of two indicators used to track progress towards achieving MDG 5 is the proportion of births attended by skilled health personnel [3]. Global policies also aim at shifting the place of delivery from home to hospital as one of the strategies to improve maternal and neonatal survival [4, 5]. This has led to unprecedented increases in facility births in several countries [6, 7].

India is one of the countries to have adopted a conditional cash transfer scheme to encourage facility deliveries, being implemented since 2005. Facility deliveries in India have since expanded from 40.7 % in 2005–06 to 72.9 % in 2009–10 [8]. There is some research evidence associating facility deliveries with a decline in perinatal mortality and still births in India [9]. It has also led to an increase in institutional delivery by at-risk mothers, which has the potential to reduce maternal morbidity and mortality [10]. Expanding health system effectiveness and socio-economic development, along with rising institutional deliveries have brought down maternal mortality ratio (MMR) over the years from 390 in 2000 to 179 in 2012 [2, 11]. However, India still accounts for 19 % of global maternal deaths and is still far from achieving the fifth MDG target of reducing maternal mortality to 100 [2].

One of the reasons for persistently low utilization of facility deliveries in developing countries is women’s preference for at- home deliveries. This preference is attributed to the satisfaction derived from home delivery in comparison with facility delivery based on previous experience, or perceptions surrounding these services [12‐14]. Services of traditional birth attendants continue to be widely used as community members believe health services are necessary only when there are complications [15]. On the other hand, there have been reports of unkind treatment by health facility staff [12, 16] poor attitude and absenteeism [14, 17] and overall perceived poor quality of health services, [14, 17‐20] as deterrents to seeking facility delivery. A study showed that women with complications would delay or avoid seeking care in a facility if they had a previous experience of disrespectful treatment by staff [14]. Other factors related to the level of satisfaction with, or preference for home over facility deliveries in developing countries include the distance of health facilities, costs, and quicker access to traditional birth attendants [13‐17, 21, 22]. Good infrastructure is also an important determinant, especially in facilities. Proper waiting areas, beds, housekeeping services, electricity, water and clean toilets are basic structural requirements which affect women’s satisfaction with services [23‐25]. Availability and quality of human resources, medicines, and equipment are also important [26‐28]. Prompt care, constant attention, perceived ‘good’ care, sharing of information on her condition with the woman and comforting her are other themes that determine maternal satisfaction [23, 27, 29]. Outcome ultimately determines overall maternal perception. Safety and health of mother and child after delivery significantly influence a positive assessment of care by the mother [24, 28, 30].

Few studies in India have explored women’s preferences for home, public or private health facility for delivery [20]. Some studies have explored determinants of utilization of facility delivery [19, 31, 32]. In India, traditionally medical attention is deemed unnecessary as delivery is believed to be a natural process [12, 13, 19] and an unassisted birth is considered a sign of courage [13]. Sometimes, economic status may influence decisions regarding place of delivery, even more than access, especially when choosing between private and public healthcare. Utilization of private health services is seen as an index of wealth and status [19]. Public health facilities are the main source of affordable facility deliveries for India’s poor, and a good patient experience would be a critical factor for enhancing facility deliveries [17]. There are, however, instances where women expressed a desire for facility delivery but still ended up delivering at home. The most common reason for this has been noted as the rapid progression of labor with no time to reach a facility, thereby leading to home deliveries [16, 17]. Other factors inhibiting facility delivery include resistance by older women relatives, and sometimes women being sent back home from the facility as delivery was not due that day [16]. In spite of the conditional cash incentive scheme introduced in India, there are states like Jharkhand where 60 % of deliveries continue to take place at home [8].

In this context, it is important to understand the experience of care of women who have delivered at home vis-a-vis those who’ve delivered at a health facility, analyzing any differences so that services can be improved, with the goal to promote facility births, particularly in areas where women still prefer to home births. This study aims to understand women’s experiences of delivery care for home and facility births and the factors that influence women’s decisions regarding their next place of delivery.

Table 1 presents the socio-economic, demographic and pregnancy-related characteristics of the respondents. The mean age of women interviewed was 24 years, with 52 % belonging to the age-group of 19–24 years (Table 1). They were predominantly Hindu, with Muslims and others constituting only a fifth of the total respondents. Socially vulnerable caste and tribe groups in India are constitutionally categorized as Scheduled Castes and Scheduled Tribes respectively while ‘general castes’ refer to the non-vulnerable groups. About 80 % of the women belonged to Scheduled Castes and Tribes (74 %) and Other Backward Castes (6 %). Literacy levels were low with 54 % women without any formal education. Most women lived in joint families (69 %) and belonged to households falling in the two lowest income quintiles (86 %). Among pregnancy characteristics, the parity was 2.4 and the mean number of living children per woman was 2.2. The sex of the index child was a boy for 49 % women and girl for 51 % women. The study found significant differences between women with home and facility births for age, caste, religion, education level, type of household, parity, and number of living children.

The study findings show that there is no major difference in the experience of care between home and facility births, the only difference in care being with regard to pain relief through massage/medicine and the low cost of delivery for those having home births. Findings show a growing preference for facility delivery among women in the study area. The major reasons for this preference were the availability of good supplies i.e. medicine and the perceived health benefits for mother and baby.

In South and Southeast Asia, even recently, more than 70 % of all births in the lowest two wealth quintiles occurred at home [13]. Women consider the Traditional Birth Attendant (TBA) as a culturally acceptable and competent health worker [41]. Residing in the same community, she offers respectful, prompt care and personalized attention to the woman during delivery [36]. Poor accessibility of the institution and factors like lower maternal education, being a rural resident and multi-parity increase the likelihood of home delivery [13, 14, 17, 21, 42]. On the other hand, evidence from developed countries shows that convenience, privacy, and respect are also very important determinants of a woman’s preference for home deliveries [12, 16, 41]. However, the findings of this study show that there is no major difference in the experience of care between facility and home births, in terms of promptness and respectful care. For process of care indicators like time taken by provider to attend after onset of labor, women not being left alone in delivery room, sharing of information about progression of labor, delivery conducted in a secluded place and absence of male members, the experience of care was same for women who have delivered at home and at the facility.

This study’s findings show that a significant proportion of women, who delivered either at a facility (74.4 %) or at home (63 %), were inclined to deliver their next child at the health facility. One of the main reasons for their preference is that they perceive better availability of medicines and supplies, and improved health outcomes of both mother and newborn at facilities. There are other studies from India which have shown that safety of mother and child was the prime concern for households opting for institutional delivery, along with monetary incentives under the conditional cash transfer scheme, and motivation by community health workers [43]. Utilization of public facility is also related to socio-cultural factors like religion, caste, age, education and economic condition [43, 44].

Findings for unadjusted odds ratios in this study show that women with higher education level, belonging to higher age group, who have previously had facility delivery, and those with health problems post-delivery were more likely to give birth at a health facility in the future. Unadjusted figures show those who have received antenatal checkup, belonging to higher income level, and living in joint family, are also more likely to deliver their next child at a health facility. Other studies in similar settings have also shown that the number of ANC visits is an important factor leading towards delivery at an institution, as during ANC visits it is most likely that the women receive counseling from providers about the importance of safe delivery and are encouraged to deliver at a health facility [45‐47]. Controlling for other variables, this study found that the mother’s education, age, and current place of delivery are the factors that strongly predict their decision on the place of future delivery. This finding is consistent with earlier studies, which have shown educational status of mothers to be one of the most significant associated factors for utilization of institutional delivery [41‐43, 46, 48‐52]. Our study also showed that mothers whose last delivery was at a facility and who had a good experience of care were more likely to go again for a facility delivery. This highlights the need for sustaining the quality of technical as well as interpersonal care in institutions [43]. Particularly, women’s perspective needs to be taken into account in facility quality improvement initiatives to make services more responsive to their needs. Women’s preference towards facility delivery is a significant positive aspect and measures need to be taken to address their preferences so that there is improved utilization of services.

This study is a community-based survey to assess the predictors of facility deliveries in rural eastern India, which is relevant to other developing countries with a high proportion of home births. In spite of a government-led cash incentive program to promote institutional delivery, a significant number of deliveries are happening at home in India [8]. The reasons for women’s willingness to deliver at a facility include the availability of medicines and supplies, potential health benefits for the mother and newborn and the perception of good care from the providers. This is aligned with women’s experience of care where they have stated better management of pain during labor at the facility than at home. Women who are more educated with higher income levels, belong to a higher age group and have had an antenatal check-up are more likely to deliver at a health facility. Improving the quality of public maternal health services, particularly the factors that determine women’s decision, if assessed regularly and incorporated as part of quality improvement programs at the facility can result in increased maternal satisfaction, thus improving the demand for facility births.