Background
While motherhood is a positive and fulfilling experience for many women, pregnancy and childbirth can also be associated with suffering, ill health and death. In 2000, the Millennium Development Goals (MDGs) were developed at a United Nations summit, and two of the eight MDGs relate specifically to maternal and child health: reducing child mortality (MDG 4) and improving maternal health (MDG 5). While some improvement has been made since 2000, for many areas of the world, pregnancy, childbirth and early childhood remain major contributors to morbidity and mortality. For example, globally in 2009, 3.3 million newborns died within the first week of life, and in 2010, 287,000 women died from complications that could have been prevented, including severe bleeding, infections, and eclampsia [
1,
2]. Life-long disabilities related to childbirth, such as obstetric fistula for women and cerebral palsy for infants, also remain major problems. Importantly, morbidity and mortality during pregnancy, childbirth and early childhood are not evenly distributed globally; 99% of maternal and neonatal morbidities and mortalities occur in low income countries, with more than half occurring in sub-Saharan Africa and one third occurring in South Asia [
3].
Despite recent economic growth and success, India continues to be faced with poor maternal and child health outcomes. India accounts for more than 20% of the global burden of maternal mortality, with 187 deaths per 100 000 live births [
4]. The infant mortality rate is 44 per 1000 live births and almost one-third of global neonatal deaths occur in India (neonatal mortality rate is 32 per 1000 live births) [
5]. In addition, only 57% of births in India in 2009 were assisted by a skilled birth attendant [
6]. While the proportion of institutional deliveries is increasing, up to nearly 70% in 2013–14 [
7], the skill level of attendants at institutions is not certain. Similar to high and middle-income countries, maternal, neonatal and child health outcomes vary along social, economic and geographic lines. Thus, a key goal of the Government of India is to improve maternal and child health, with a specific focus on the rural populations who predominantly face economic disadvantage. The Government of India launched the National Rural Health Mission (NRHM) in April 2005 to improve the access of rural populations to effective primary health care, including an increased uptake of institutional delivery among rural communities.
The Karnataka Health Promotion Trust (KHPT) and the University of Manitoba (UM) have provided technical support since 2008 to the NRHM in Karnataka state, in south India. The main goals have been to improve availability, accessibility, quality, and utilization of maternal, neonatal and child health (MNCH) services for rural communities with the poorest outcomes. A qualitative study was undertaken by KHPT and UM to elucidate social and cultural knowledge and practices associated with pregnancy, delivery and care of the neonate, which has been used to inform the outreach and communication elements of their programs. The focus of this paper is on women’s preferred site for birthing their children (i.e. home vs. government hospital vs. private hospital). Delivery site is an issue of importance in India because of the adverse outcomes for women and infants associated with unattended births and births with under-skilled attendants. Understanding women’s preferences and the factors women consider important in identifying preferred sites will assist in better understanding service use patterns and ultimately may assist with increased use of skilled attendants and institutional deliveries.
Discussion
Our study sheds light on local understandings and relative importance of health care quality that shaped delivery site preferences of pregnant women and new mothers in three districts of north Karnataka. Women’s perspectives are important because they are the primary service users at the time of delivery and important stakeholders of NRHM interventions. Pregnant and new mothers’ preferences for delivering at home or at private or public hospitals revealed elements of both convergence and multiplicity, and can be summarized in terms of three components of quality of care: a) financial, structural, and geographical
accessibility, b) social and cultural
acceptability, and c)
safety and efficacy. This study is among the first in India to use qualitative methods to explore women’s preferences for place of delivery and the factors influencing their perspectives. There have been few mixed-methods or qualitative studies that have assessed the quality of care or reasons for delivery site preferences at public versus private institutions in India [
10,
15-
17]. Instead, most previous studies on birthing location have been quantitative analyses of large-scale National Family Health Surveys or smaller-scale surveys that have assessed factors associated with different delivery sites [
18-
23].
Participants in our study gave their views on the three delivery sites: home, private or public (government) institutions. Government hospitals were seen as having relevant and effective medical treatment and services in some cases, but many respondents also discussed the lack of quality components such as basic amenities (e.g. water), cleanliness, and control over the situation. Women did not highlight the lower cost of government hospitals as a particular reason for preferring those facilities, but did mention the drawback of costs that could be incurred at government hospitals. Receipt of incentives was variable, and access to government hospitals by ambulance with the help of the ASHAs was sometimes but not always possible. Social acceptability was a major point of discussion among study participants. Treatment by staff at government hospitals was inconsistent and in some cases, particularly in Gulbarga, there were experiences of maltreatment. This inconsistency in quality of care at government hospitals was echoed in a study completed across rural India [
20]. Similar experiences of poor treatment were found in the slums of New Delhi, where 15% of women reported being shouted at or slapped during labour at government institutions, compared to 3% during private hospital deliveries [
21].
In contrast, private hospitals were seen in a more favourable light, with more consistently positive views. Treatment by staff and the services provided were seen to be acceptable. However, some women stated that C-sections were more common at private hospitals, and other commonly occurring medical procedures were too invasive and potentially unsafe, thus they were viewed with wariness. This supports the findings by Hulton and colleagues’ study on the quality of hospitals in a New Delhi slum [
21]. They found that women delivering at government hospitals reported mixed treatment while those delivering at private hospitals generally reported more positive treatment. In their study they also found an over-use of medical procedures at private hospitals, which they linked to the profits that can be made by doing C-sections: “the costing of clinical interventions by private providers provides a financial incentive which may compromise clinical judgment. The reverse is true for the public sector… Neither of these situations is optimal in terms of supporting high quality institutional maternity care” [
21]. Financial access was the most negative characteristic of private care according to the women, which led to the perception that private hospitals are exclusively for wealthier families and therefore associated with some inequity. Nonetheless, some saw the high cost as a marker of quality, which may have combined with the positive actual and perceived impressions on the quality of care at private institutions. The wide preference for private hospitals in India supports Thind and colleagues’ finding that when the mothers were the primary decision-maker, the majority preferred the private hospital delivery in Maharashtra state [
23].
The views around home delivery were also mixed and not simply based on a lack of education or poverty level of the users [
24]. While home delivery was generally becoming less favourable among the younger generation, it remains a preferable option for non-complicated deliveries by many women and was sometimes determined at antenatal care visits. Thus, the socio-cultural acceptability of having a “normal delivery” at home, often attended by a traditional birth attendant or occasionally by a doctor, made it preferable to delivering at hospitals. These were similar to the reasons for home birth found elsewhere [
24]. Further, access was not an issue for home delivery as there were no service costs associated and no need to travel externally. Yet there were some women in all districts who stated that home delivery was more risky and painful in general and thus less safe or preferable compared to hospital delivery.
An analysis of the components of quality of care in relation to each delivery site in respondents’ accounts revealed some key themes with implications for MNCH interventions in the region. The first theme is that both personal and others’ experiences of quality of care influenced women’s preferences for a certain delivery site. Negative experiences, whether experienced personally or by others, had a significant impact on the perceptions women held of a given delivery site and thereby reinforced their preferences. Inconsistent experiences at government hospitals compared to more consistently positive experiences and views of private hospitals led to a preference for the latter. This is consistent with Sidney and colleagues’ finding that 30% of 418 new mothers in Ujjain district of Madhya Pradesh used private facilities because of their good reputation or past experiences [
24]. The perception that home delivery was becoming generally less favourable, but appropriate when there was an uncomplicated delivery, was also important in guiding their preferences. This is also supported by Sidney and colleagues’ findings that delivering at home was related to whether the mother “felt previous deliveries were easy so there was no need” [
24]. Thus, it is important to improve women’s experiences at government hospitals in areas deemed important to them so as to improve perceptions and therefore facilitate increased uptake of government facilities for infant delivery.
The second theme centres on the continued importance of access issues and the need for more consistent outreach, better ambulance services, and more efficient receipt of financial or other incentives. Not all women were able to travel to the hospitals by ambulance because of limited availability, which was also found in Sidney and colleagues’ study [
24]. Nor did participants’ always know about or receive incentives. Thus, the lesser costs associated with government hospitals and the possibility of incentives for delivering at government hospitals did not diminish preference for and perceptions of better care and outcomes at private hospitals. The high costs of the private hospital concerned all women regardless of their positioning in relation to the poverty line. This contrasts with the finding in other studies that being above the poverty line correlated with institutional and especially private delivery [
19,
20,
23,
25]. Our finding may be explained in part by Sidney and colleagues’ observation that the positive reputation of private institutions was more important than socio-economic status with respect to delivery site choices, and that while some rural women may be above the poverty line, they may still be relatively poor compared to those in urban areas of India [
24]. The importance placed on quality in terms of acceptability and safety, which was generally seen as higher at private hospitals, further fuelled the concern about access to private deliveries. At the same time, greater costs also were sometimes seen as a marker of quality of care at the private hospitals. This suggests that solely incentivizing government hospital delivery with a cash transfer under the JSY scheme, without addressing the other issues women consider in deciding on delivery site, will continue to lead women and possibly other decision-makers in their families to desire private deliveries. This has been found previously [
15,
21,
22,
24,
25]. Improving equity through the provision of schemes to those below poverty and scheduled tribe and caste has been a challenge according to other studies that show usage of the JSY scheme to be below 50% among these groups in other Indian states [
26]. However, the scaling up of accessible care, particularly to hard-to-reach populations, remains important.
Finally, despite ongoing access issues particularly for the most marginalized, the increasing numbers of institutional deliveries in Karnataka on average suggests that particular attention must be given to social and cultural acceptability as well as safety so as to improve perceptions and experiences when delivering at health facilities [
7]. Many studies have focussed their recommendations on supply-side issues including training more physicians and supplying more equipment and facilities in rural areas [
17,
22,
25,
27,
28]. As shown in the results of our study, the focus of NRHM interventions centers heavily on improving financial and geographical access through incentives and outreach workers to connect women to the facility. Yet in addition to this, women’s priorities and definitions of quality care in this study were directly linked to the quality of the experience at the time of delivery, including social acceptability and safety. We found that the respondents’ preferences were greatly influenced by the ability to undergo a “normal delivery” with culturally desirable and relevant amenities such as hot water, warmth and food, and with more control over the birth process. Another important factor of quality that shaped their preferences was the experience of maltreatment, particularly towards poorer women and at government institutions. This led many to favour private institutions or home delivery rather than government facilities. Previous studies have not stressed the importance of social and cultural acceptability in these terms [
15,
27], and few have stressed the need for improved treatment of lower caste or below-poverty line women [
19], despite the explicit efforts and mission of the NRHM to improve equity through improving access to institutional delivery [
14]. In their research on health-seeking behaviour, Haussman-Muela and colleagues have emphasized the need to consider the acceptability of health personnel-client dynamics, citing studies that found factors such as poor explanations on treatment, rudeness, or blaming-the-victim mentalities as potential barriers for health care. At the same time, they stress the importance of contextualizing these behaviours, for example considering the salaries, work conditions and institutional culture that may reproduce inequitable power relations and related abuse within health centres [
29]. Thus, quality of care, especially as government institutions are made more accessible, must be improved in line with women’s expectations, particularly in terms of staff treatment, provision of acceptable and safe care, and where possible, conducting “normal” deliveries with appropriate amenities.
This study has limitations. While the sample size was quite large for a qualitative study and we attempted to maximize variation in terms of relevant socio-demographic characteristics, it was not a representative sample and therefore the findings cannot be generalized to the whole population. However, with a qualitative design, the aim is to gather in-depth information to explore the variation in views rather than to determine generalizable relationships between factors. Though we attempted to compare socio-economic groups based on caste and whether respondents were above or below the poverty line, we found that respondents in all categories saw themselves as relatively poor, and though this is a relevant finding we cannot use this to make broad conclusions on how differences in socio-economic status impact delivery preferences. We developed categories inductively from the data and have gone over the interpretations of the results with stakeholders in India, however it is possible that researcher and stakeholder bias has some influence on the interpretation of the findings. Notwithstanding these limitations the study has numerous strengths. First, we recruited a large sample of women from various backgrounds and were able to conduct interviews in their most familiar language. Second, the study is grounded in the activities and experiences of those in the local environment. Partners and stakeholders represent Indian researchers, policy makers, decision-makers, and health care providers. In consultation with local communities the topic was deemed relevant and important. Third, local research assistants underwent thorough training and ongoing feedback during data collection. Finally, local women, policy-makers, decision-makers and health care providers participated in the analysis and interpretation of the findings.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SB participated in the conception and coordination of the study design and the interview guide, conducted training of interviewers, analyzing the transcripts, and writing the manuscript. AB participated in the literature review, analysis and interpretation of results, and writing of the manuscript. KG participated in the design of the study, training the interviewers, analysis and interpretation of results. AR participated in the analysis and interpretation of the results. KJ, HLM, and BMR contributed to the study design, implementation of the intervention, and interpretation of the results. SM and JB were Principal Investigators of the project and involved in project implementation. LA was involved in study design, project implementation and interpretation of the results. All authors reviewed and approved the final manuscript.
Sharon Bruce, Associate Professor, Community Health Sciences, Faculty of Medicine, University of Manitoba, Canada. Sharon.Bruce@umanitoba.ca