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Introduction: Babies born before arrival at a health facility have a higher risk of neonatal death and their mothers a higher risk of maternal death compared with those born in-facility. The study explored the reasons for mothers giving birth before arrival (BBA) at health facilities and their experiences of BBA. Methods: A qualitative research design was used. Individual and focus group interviews of BBA mothers and of nurses were undertaken at a community health centre and a district hospital in King Sabata Dalindyebo Local Municipality. Results: Reasons for BBA included a lack of transport, a lack of security at night that deterred mothers from travelling, precipitate labour, failure to identify true labour, and a lack of waiting areas at health facilities. Traditional and cultural beliefs favouring childbirth at home and nurses’ negative attitudes during antenatal care and labour influenced mothers to go to health facilities when in advanced labour. Mothers were aware of possible complications associated with BBA. Conclusion: Socio-economic, individual, cultural and health system factors influence the occurrence of BBA. Relevant parties need to address these factors to ensure that all babies in the King Sabata Dalindyebo Local Municipality are delivered within designated health facilities.
A qualitative approach was chosen as it would ‘enable participants to speak for themselves’24 and provide a deeper understanding of factors associated with BBA. Both Mthatha General Hospital and Ngangelizwe CHC, with an average of 500 and 200 deliveries per month respectively, are located in the town of Mthatha, situated in the predominantly rural Oliver Reginald Tambo District, the third most deprived of 52 districts in South Africa.25 Indicators of deprivation include the following: an estimated 59% of the population live below the poverty line; the unemployment rate is high at 44%; there is no access to piped water for 51% of households; 70% live in traditional dwellings; and 30% of households have no electricity.26 Purposeful sampling was used to select BBA mothers and nurses for interview. The most senior nurse in charge selected participants after assessing that they were likely to freely and fluently express their views. BBA mothers who presented within 3 months of delivery were recruited. The sample size was determined by data saturation, namely, when no new themes or insights were obtained, recruitment was stopped.24 The inclusion criterion for the nurses was that they must have worked at one of the study facilities for at least 1 year and must have attended to BBA mothers. For the mothers, individual in-depth interviews were conducted, whilst two focus group interviews were undertaken with the nurses, one at each site. A female research assistant trained in qualitative interviewing conducted semi-structured interviews with BBA mothers in their first language (isiXhosa), either at the hospital or at the CHC. An interview guide, based on themes identified in the literature review, was used. The guide was piloted by interviewing two mothers and minor clarifications were made to the guide. The two interviews were not included in the study. Open-ended questions were used to allow participants to freely express their views. However, probing and prompting of participants were undertaken, where necessary, to obtain clarity of information. One author (A.A.A.) facilitated the focus group interviews, whilst the research assistant took field notes. Focus groups use group dynamics and different forms of communication such as teasing, jokes and arguing to explore views.27 The researchers considered that focus groups would be sufficient for clarifying nurses’ views. The focus groups were conducted in English. All the interviews were audiotaped and field notes were taken by the interviewer to record any emotions displayed or behavioural cues. The research assistant transcribed audiotaped recordings of the interviews and field notes and translated the individual interviews into English. To ensure that transcription was accurate, an educator whose first language was isiXhosa cross-checked excerpts of the transcriptions with the recordings. The ‘framework approach’ was used to inductively analyse data.28 A ‘cut and paste’ using a word processor was used to group selection of data. Themes emerging from the focus group discussions and the in-depth interviews were combined, compared and triangulated using content analysis. Four constructs were utilised to ensure the trustworthiness of the present study.29 For credibility, triangulating of data collection methods was utilised (focus group and in-depth interviews) as well as triangulation of sources of the data by interviewing BBA mothers and nurses. The validity of data collected was ensured by having an independent translator randomly verify the accuracy and completeness of the excerpts from the transcripts with the audiotaped interviews and the translation of transcripts. For transferability, sufficient, rich and thick descriptions are given for readers to understand if the results can apply to other settings. For dependability, established research methodology was used with sufficient detail to allow a reader to judge its reliability. For confirmability, triangulation was used to reduce the effect of possible researchers’ bias. The author A.A.A. is a medical practitioner trained in a predominantly biomedical paradigm, whilst the research assistant (Phelo Sithole) is a graduate in social sciences.
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