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Background. Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda. Methods. We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach. Results. Eighteen women (60%) preferred to deliver from home. Women’s referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a “natural” and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as “affordable,” “supportive,” and “convenient”; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women. Conclusion. Women’s psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery.
This study used a qualitative interview study design to identify and understand psychosocial and cultural factors that motivate women to choose and/or participate in unskilled home delivery among postpartum women in Mbarara district, rural southwestern Uganda. The study was conducted between December 2018 and March 2019 in the Mbarara district of rural southwestern Uganda. Mbarara district is one of the densely populated districts in the Ankole region with one of the highest maternal mortality ratios of 489 per 100,000 women in Uganda [29]. Uganda’s public health system is organized into seven tiers with national and regional referral hospitals, general district hospitals, and four levels of community health centers (HC). The village level (HC1) is operated by village health teams (VHTs). The VHTs are community volunteers identified by their community members and are given basic training on major health programs, so they can mobilize and sensitize communities to actively participate in utilizing health services [30]. According to the Uganda Ministry of Health, VHTs also act as an important link between the communities and health facilities and can provide treatment of uncomplicated diseases like malaria, pneumonia, worm infestations, diarrhea, and mass drug administration for Neglected Tropical Diseases. VHTs mobilize communities during specific health campaigns and community disease surveillance activities through active data collection and reporting. Staffing and available services vary across the four levels: HCIII and HCIV should offer Emergency Obstetrics Care (EMOC), whereas HCI and HCII serve as low resource referral units which are not able to provide EMOC and have no ambulances and blood transfusion services [7]. In total, there are about 10 public facilities within a 20 km radius from Mbarara Regional Referral Hospital, the main teaching hospital for the Mbarara University of Science and Technology. Private providers operate in parallel to the public system to provide maternal health care. The research team comprised of seven senior investigators, inclusive of epidemiologists (ECA and CO), an obstetrician (GRM), a medical anthropologist (NCW), a maternal/reproductive health expert (LTM), a nurse (JN), and a health informatics specialist (AM). Based on our previous research and working experiences in maternal health in Uganda, the team sought to explore reasons for low utilization of maternity services in Uganda. The two male and female research assistants were both social scientists, independently hired and trained to conduct research in human subjects. These two research assistants generated transcripts but were not involved in concept development or coding of data. This multidisciplinary team leveraged on their expertise and experience with maternal health issues in Uganda to design, conduct, analyze, and present findings from this study. Contact with one of the VHTs based in each of the study villages was initiated by a trained research assistant from the list of VHTs provided by the district health office. A purposive qualitative sampling strategy was used to construct a sample of postpartum women with varied knowledge and experiences of pregnancy, antenatal care, and childbirth. Women who had had their last delivery within the last three months were identified with the help of an existing VHT contact person found in each of the 10 villages located within 20 km from Mbarara Regional Referral Hospital. Trained research assistants initiated a telephone contact to the identified women to seek for permission to visit them for an interview. Research assistants obtained voluntary written informed consent from all eligible participants in the local language in a private area of their homes, communities, or study office. All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form. Three women from each of the 10 villages with different home or facility birthing experiences were purposively selected and recruited. The total sample included 15 women who had delivered from their homes and 15 who had delivered from a health facility. Eligible women (1) were adults of childbearing age (18-49 years), (2) had delivered a child in the previous three months, (3) had access to a mobile phone, and (4) were able and willing to give informed consent. Interview topics were developed using HUM. Data collection consisted of individual, open-ended interviews with each of the study participants (N = 30 interviews). A preliminary interview guide was developed and pilot tested by the primary author among women in one of the 10 participating villages using the constructs of the Healthcare service Utilization Model that demonstrates the factors that lead to the use of health services (Figure 1). The guide was revised based on the results of the pilot test. Topics included in the final version of the guide were as follows: (1) perceptions of pregnancy and childbirth, (2) experiences of previous pregnancy or pregnancies, (3) experiences of ANC, (4) engagement with health care providers within a facility, (5) social support, and (6) childbirth experiences. Individualized probes were used to elicit details corresponding to each topic. As the interviews were conducted, emerging content was continuously reviewed by the primary and senior authors to sharpen the interview questions and identify new probes. Demographic information (e.g., age, occupation, and educational background) was collected at the outset of each interview. Healthcare service Utilization Model (HUM) adapted to factors relevant to ANC utilization and skilled delivery. All interviews took place in a private location mutually agreed upon by the participant and the interviewer. Interviews were conducted in the local language (Runyankole) and digitally recorded. Interviews lasted 60-90 minutes. Qualitative interviews were digitally recorded with the participant’s permission and transcribed. Two Ugandan research assistants transcribed the interviews from the local language directly to English. The two independent male and female research assistants were both social scientists trained in research in human subjects. These two research assistants generated transcripts but were not involved in concept development or coding of data. The aim of this qualitative data analysis was to inductively construct categories describing barriers to facility-based delivery. Analysis began with repeated review of transcripts to identify relevant content. The identified content served as the basis for developing a coding scheme. Coding was done in three stages, namely, (1) open coding to identify and describe women’s ideas, meaningful expressions, phenomena, or incidents highlighting their experiences during pregnancy and childbirth; (2) axial coding to relate and label codes or data that shared concepts, dimension, and properties (relationship identification); and (3) selective coding to delimit coding to the identified core variables/concepts from the data (Strauss and Corbin, 1998). Data were coded with the aid of the qualitative data management software, NVivo10 (Melbourne, Australia). Coded data were iteratively reviewed and sorted to identify themes (repeated patterns in the data). Categories were then developed to describe each identified theme. Categories consisted of descriptive labels, elaborating text to define and specify each category’s meaning, and illustrative quotes taken from the qualitative data. Data analysis was done jointly by ECA, EA, CO, JN, and GRM. Both JN and ECA coded 5 sampled transcripts and compared the results. Together with GRM and CO, we resolved disagreements until we were satisfied with the consistency in our coding. We aimed to ensure consistency in coding and did not aim for or cite interrater reliability coefficients. Although the interview topics were developed using HUM, we used an inductive content analytic approach to identify and describe psychosocial and cultural factors influencing birthing choices for unskilled home delivery and represented identified influences as descriptive categories. All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form. Permission to conduct the study was obtained from district and local community leaders. The study was reviewed and approved by the Mbarara University of Science and Technology Institutional Ethics Review Committee and the Uganda National Council for Science and Technology, Kampala, Uganda.
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