Birth location preferences of mothers and fathers in rural Ghana: Implications for pregnancy, labor and birth outcomes

BMC Pregnancy and Childbirth, Volume 15, No. 1, Year 2015

Interpretação

Background: Maternal deaths in Sub-Saharan Africa are largely preventable with health facility delivery assisted by skilled birth attendants. Examining associations of birth location preferences on pregnant women’s experiences is important to understanding delays in care seeking in the event of complications. We explored the influence of birth location preference on women’s pregnancy, labor and birth outcomes. Methods: A qualitative study conducted in rural Ghana consisted of birth narratives of mothers (n = 20) who experienced pregnancy/labor complications, and fathers (n = 18) whose partners experienced such complications in their last pregnancy. All but two women in our sample delivered in a health facility due to complications. We developed narrative summaries of each interview and iteratively coded the interviews. We then analyzed the data through coding summaries and developed analytic matrices from coded transcripts. Results: Birth delivery location preferences were split for mothers (home delivery-9; facility delivery-11), and fathers (home delivery-7; facility delivery-11). We identified two patterns of preferences and birth outcomes: 1) preference for homebirth that resulted in delayed care seeking and was likely associated with several cases of stillbirths and postpartum morbidities; 2) Preference for health facility birth that resulted in early care seeking, and possibly enabled women to avoid adverse effects of birth complications. Conclusion: Safe pregnancy and childbirth interventions should be tailored to the birth location preferences of mothers and fathers, and should include education on the development of birth preparedness plans to access timely delivery related care. Improving access to and the quality of care at health facilities will also be crucial to facilitating use of facility-based delivery care in rural Ghana. The present study is based on a baseline qualitative assessment of barriers faced by pregnant women in accessing health care services during pregnancy and delivery in Ghana to inform a community-level quality improvement intervention to promote maternal and newborn health services access and utilization. We collected data in two districts, one in the Northern Region (NR) and the other in the Central Region (CR) between May and June of 2012. We purposively sampled mothers (n = 20) who experienced pregnancy or labor complications themselves or whose newborns experienced complications, and fathers (n = 18) whose wives/partners experienced such complications. The fathers and mothers sampled were not partners. Complications included severe ailments experienced by women or newborns (e.g. severe bleeding, infections, or obstructed labor), which resulted in an urgent visit to a health facility. As an inclusion criteria women, or their newborns, had to have been referred from a community-level health post to a health center, or from the health center to a high-level facility like a hospital in the last year. This was in order to ensure that participants selected had experience with pregnancy complications. Nearly all women in our sample delivered in health facilities due to complications; the two women who experienced homebirths sought facility care for postnatal complications. Additional criteria were age 18 years or older, and natives of the Northern and Central Region. Health workers from local health centers generated a list of women who experienced complications. Based on this list, we worked with the assistance of community health workers/ local assemblymen to identify mothers and fathers in communities across the two districts. We visited the households of women and husbands/ male partners of women who met the inclusion criteria. We interviewed those who agreed to participate, and the age range of the participants was 18–45. Participants from the Northern region were of Konkomba or Nanumba ethnicity. The Konkomba people are either Christians or traditionalists, and the Nanumbas are mostly Moslems. Participants in the Central region were of the Fante ethnicity and predominantly Christian. A total of 38 birth narrative interviews were conducted, following the principle of data saturation – i.e. the point at which collecting more data did not yield new information or themes related to our research study [33]. We developed a semi-structured interview guide based on evidence from the literature and multiple reviews from the research team. A male and female Ghanaian research assistant (RA) in each study region, fluent in the local languages of the regions, underwent a two-week training on conducting field interviews. The interview guide was field tested before final revisions were made. The male and female RAs interviewed male and female participants, respectively. Participants were asked to describe pregnancy and labor experiences, use of health services during pregnancy and labor, birth delivery preferences and plans and support received during pregnancy. Sample questions included the following: 1) Describe what you remember about your pregnancy experience, labor and delivery experience. 2) During your pregnancy did you have a place in mind you preferred to give birth? 3) What were reasons for your choice of birth delivery place? 4) What care did you receive for your pregnancy? Verbal informed consent was obtained from all study participants. The interviews lasted for about an hour each, and participants were provided with bars of soaps as an appreciation for their participation. RAs conducted interviews in two local Ghanaian languages (Twi and Dagbani). The interviews were audio recorded, transcribed, and translated to English. We obtained ethics review approval from the Ghana Health Service Ethical Review Committee and the University of North Carolina at Chapel Hill Institutional Review Board. Following data collection we conducted close readings of all birth narrative interviews and wrote narrative summaries on each participant’s birth experience. Based on these summaries, we generated preliminary descriptive codes and memos of participants’ birth preferences. Then, through discussion of emergent findings with the research team including the local Ghanaian PI, and subsequent review of the transcripts, we developed a core set of codes in order to conduct thematic analysis. The first author applied these codes to the birth narratives using Atlas.ti software (version 7.0, Scientific Software Development GmbH, Eden Prairie, MN), during which the initial coding scheme was modified and additional codes were added. We then reviewed code outputs and developed code summaries and analytic matrices [34, 35]. The code summaries provided contextual information on health seeking experiences that resulted in women’s birth outcomes. The matrices enabled comparison between participants with home versus facility birth preferences on their reasons for birth location preferences, pregnancy and labor experiences, and resulting birth outcomes.

AI Digest

Study Justification:

– Maternal deaths in Sub-Saharan Africa can be prevented with health facility delivery assisted by skilled birth attendants.
– Examining birth location preferences is important to understand delays in care seeking in the event of complications.
– Understanding the influence of birth location preference on pregnancy, labor, and birth outcomes can inform interventions to improve maternal and newborn health.

Highlights:

– Birth delivery location preferences were split between home delivery and facility delivery for both mothers and fathers.
– Preference for homebirth resulted in delayed care seeking and was associated with stillbirths and postpartum morbidities.
– Preference for health facility birth resulted in early care seeking and potentially avoided adverse effects of birth complications.
– Safe pregnancy and childbirth interventions should be tailored to birth location preferences and include education on birth preparedness plans.

Recommendations:

– Tailor interventions to the birth location preferences of mothers and fathers.
– Include education on the development of birth preparedness plans to access timely delivery related care.
– Improve access to and the quality of care at health facilities in rural Ghana.

Key Role Players:

– Community health workers
– Local assemblymen
– Health workers from local health centers
– Research assistants fluent in local languages

Cost Items for Planning Recommendations:

– Training for research assistants
– Translation services
– Audio recording equipment
– Transcription services
– Soap bars as appreciation for participant’s participation
– Ethical review approval
– Software for data analysis (Atlas.ti)
– Publication costs

Força da prova

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a qualitative study conducted in rural Ghana. The study collected data through birth narrative interviews of mothers and fathers who experienced pregnancy or labor complications. The interviews were transcribed, translated, and analyzed using thematic analysis. The study found that birth location preferences influenced pregnancy, labor, and birth outcomes, with preference for homebirth resulting in delayed care seeking and adverse effects, while preference for health facility birth enabled early care seeking and better outcomes. The evidence is based on a relatively small sample size (n=20 mothers, n=18 fathers) and may not be generalizable to other populations. To improve the strength of the evidence, future studies could consider increasing the sample size and conducting quantitative analyses to further explore the associations between birth location preferences and outcomes.

Resumo

The present study is based on a baseline qualitative assessment of barriers faced by pregnant women in accessing health care services during pregnancy and delivery in Ghana to inform a community-level quality improvement intervention to promote maternal and newborn health services access and utilization. We collected data in two districts, one in the Northern Region (NR) and the other in the Central Region (CR) between May and June of 2012. We purposively sampled mothers (n = 20) who experienced pregnancy or labor complications themselves or whose newborns experienced complications, and fathers (n = 18) whose wives/partners experienced such complications. The fathers and mothers sampled were not partners. Complications included severe ailments experienced by women or newborns (e.g. severe bleeding, infections, or obstructed labor), which resulted in an urgent visit to a health facility. As an inclusion criteria women, or their newborns, had to have been referred from a community-level health post to a health center, or from the health center to a high-level facility like a hospital in the last year. This was in order to ensure that participants selected had experience with pregnancy complications. Nearly all women in our sample delivered in health facilities due to complications; the two women who experienced homebirths sought facility care for postnatal complications. Additional criteria were age 18 years or older, and natives of the Northern and Central Region. Health workers from local health centers generated a list of women who experienced complications. Based on this list, we worked with the assistance of community health workers/ local assemblymen to identify mothers and fathers in communities across the two districts. We visited the households of women and husbands/ male partners of women who met the inclusion criteria. We interviewed those who agreed to participate, and the age range of the participants was 18–45. Participants from the Northern region were of Konkomba or Nanumba ethnicity. The Konkomba people are either Christians or traditionalists, and the Nanumbas are mostly Moslems. Participants in the Central region were of the Fante ethnicity and predominantly Christian. A total of 38 birth narrative interviews were conducted, following the principle of data saturation – i.e. the point at which collecting more data did not yield new information or themes related to our research study [33]. We developed a semi-structured interview guide based on evidence from the literature and multiple reviews from the research team. A male and female Ghanaian research assistant (RA) in each study region, fluent in the local languages of the regions, underwent a two-week training on conducting field interviews. The interview guide was field tested before final revisions were made. The male and female RAs interviewed male and female participants, respectively. Participants were asked to describe pregnancy and labor experiences, use of health services during pregnancy and labor, birth delivery preferences and plans and support received during pregnancy. Sample questions included the following: 1) Describe what you remember about your pregnancy experience, labor and delivery experience. 2) During your pregnancy did you have a place in mind you preferred to give birth? 3) What were reasons for your choice of birth delivery place? 4) What care did you receive for your pregnancy? Verbal informed consent was obtained from all study participants. The interviews lasted for about an hour each, and participants were provided with bars of soaps as an appreciation for their participation. RAs conducted interviews in two local Ghanaian languages (Twi and Dagbani). The interviews were audio recorded, transcribed, and translated to English. We obtained ethics review approval from the Ghana Health Service Ethical Review Committee and the University of North Carolina at Chapel Hill Institutional Review Board. Following data collection we conducted close readings of all birth narrative interviews and wrote narrative summaries on each participant’s birth experience. Based on these summaries, we generated preliminary descriptive codes and memos of participants’ birth preferences. Then, through discussion of emergent findings with the research team including the local Ghanaian PI, and subsequent review of the transcripts, we developed a core set of codes in order to conduct thematic analysis. The first author applied these codes to the birth narratives using Atlas.ti software (version 7.0, Scientific Software Development GmbH, Eden Prairie, MN), during which the initial coding scheme was modified and additional codes were added. We then reviewed code outputs and developed code summaries and analytic matrices [34, 35]. The code summaries provided contextual information on health seeking experiences that resulted in women’s birth outcomes. The matrices enabled comparison between participants with home versus facility birth preferences on their reasons for birth location preferences, pregnancy and labor experiences, and resulting birth outcomes.

Materiais

N/A

Inovações

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Community-based education programs: Implementing educational programs that target both mothers and fathers in rural communities, providing information on the importance of health facility delivery and skilled birth attendants. This can help address misconceptions and encourage early care seeking.

2. Birth preparedness plans: Developing and promoting birth preparedness plans that outline the necessary steps for accessing timely delivery-related care. This can include identifying the nearest health facility, arranging transportation, and saving money for potential expenses.

3. Mobile health technology: Utilizing mobile phones and other digital platforms to provide information and reminders to pregnant women and their partners. This can include appointment reminders, educational messages, and emergency contact information.

4. Strengthening health facilities: Improving the quality of care and availability of services at health facilities in rural areas. This can involve training healthcare providers, ensuring the availability of essential equipment and supplies, and addressing infrastructure challenges.

5. Community health workers: Increasing the presence and capacity of community health workers who can provide basic maternal health services, conduct home visits, and refer women to health facilities when necessary.

6. Addressing cultural preferences: Tailoring interventions to address cultural preferences for homebirth while emphasizing the importance of skilled birth attendants and the potential risks associated with complications.

It is important to note that these recommendations are based on the specific context of the study in rural Ghana. Implementing these innovations would require further research, collaboration with local stakeholders, and consideration of the unique challenges and resources available in each setting.

AI Innovations Description

Based on the study, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Tailor interventions to birth location preferences: Safe pregnancy and childbirth interventions should be tailored to the birth location preferences of both mothers and fathers. This means providing education and support for both homebirth and facility birth preferences. By understanding and addressing the preferences of expectant parents, healthcare providers can better meet their needs and encourage timely care seeking.

2. Develop birth preparedness plans: Education on the development of birth preparedness plans should be provided to pregnant women and their partners. These plans should include information on the importance of timely access to delivery-related care and the potential risks associated with delayed care seeking. By empowering expectant parents with knowledge and resources, they can better navigate the healthcare system and make informed decisions about their birth preferences.

3. Improve access to and quality of care at health facilities: Enhancing access to and the quality of care at health facilities is crucial to encouraging the use of facility-based delivery care. This can be achieved through various means, such as increasing the number of healthcare facilities in rural areas, training and equipping healthcare providers, and implementing quality improvement initiatives. By ensuring that health facilities are readily available and provide high-quality care, more pregnant women will be motivated to seek care at these facilities.

By implementing these recommendations, the innovation aims to improve access to maternal health services, reduce delays in care seeking, and ultimately prevent maternal deaths and complications in rural Ghana.

AI Innovations Methodology

Based on the study, here are some potential recommendations to improve access to maternal health:

1. Tailor interventions to birth location preferences: Develop interventions that take into account the preferences of mothers and fathers regarding birth location. This could involve providing education and information about the benefits of facility-based delivery, as well as addressing any concerns or misconceptions about giving birth in a health facility.

2. Improve birth preparedness plans: Provide education and support to pregnant women and their families on developing birth preparedness plans. This could include information on when to seek care, what to expect during labor and delivery, and how to access timely delivery-related care.

3. Enhance access to and quality of care at health facilities: Invest in improving the availability and quality of maternal health services at health facilities in rural areas. This could involve training and deploying skilled birth attendants, ensuring the availability of necessary medical supplies and equipment, and improving infrastructure and transportation options for pregnant women.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the percentage of pregnant women delivering in health facilities, the percentage of women receiving prenatal care, or the average distance traveled to reach a health facility.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This could involve conducting surveys, interviews, or reviewing existing data sources.

3. Develop a simulation model: Create a simulation model that incorporates the potential impact of the recommendations on the identified indicators. This could involve using statistical techniques, such as regression analysis or mathematical modeling, to estimate the expected changes in the indicators based on the proposed interventions.

4. Validate the model: Validate the simulation model by comparing its predictions with real-world data or conducting sensitivity analyses to assess the robustness of the model.

5. Run simulations: Use the validated model to simulate different scenarios, such as varying levels of intervention implementation or different target populations. This will help estimate the potential impact of the recommendations on improving access to maternal health.

6. Analyze results: Analyze the simulation results to understand the potential benefits and trade-offs of the recommendations. This could involve comparing different scenarios, identifying key drivers of change, and assessing the cost-effectiveness of the interventions.

7. Communicate findings: Present the findings of the simulation study to stakeholders, such as policymakers, healthcare providers, and community members. This will help inform decision-making and prioritize interventions that have the greatest potential for improving access to maternal health.

It is important to note that the methodology described above is a general framework, and the specific details may vary depending on the context and available data.

Autor

Dima Health

Statistics:

Citations: 20

Identifiers:

DOI: 10.1186/s12884-015-0604-2

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ghana

Study Design:

Cross Sectional Study, Grounded Theory, Narrative Study, randomised-control-trial

Study Approach:

Qualitative

Participants Gender:

Male & Female

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