Women’s Choice to Deliver at Home: Understanding the Psychosocial and Cultural Factors Influencing Birthing Choices for Unskilled Home Delivery among Women in Southwestern Uganda

Journal of Pregnancy, Volume 2020, Year 2020

Interpretação

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.

AI Digest

Study Justification:

– The study aims to understand the psychosocial and cultural factors that influence women’s choices to have unskilled home deliveries in rural southwestern Uganda.
– This is important because the utilization of perinatal services in Uganda is low, leading to high rates of unskilled home deliveries, which can be life-threatening.
– By identifying these factors, interventions can be developed to address barriers to healthcare utilization and promote safe facility deliveries.

Study Highlights:

– The study used a qualitative interview design to gather in-depth information from 30 postpartum women in rural southwestern Uganda.
– The findings suggest that women choose home delivery due to financial dependency, desire for a “natural” childbirth, dissatisfaction with facility-based care, belief in fate, access to alternative birthing help in their communities, and gender and traditional norms.
– These factors influence women’s decisions to pursue home delivery and highlight the need for interventions to increase perceived need and motivate women to seek facility delivery.

Study Recommendations:

– Interventions should be developed to address the barriers to healthcare utilization identified in the study.
– A multipronged approach is needed to debunk misconceptions, increase perceived need for facility delivery, and motivate women to seek skilled care.
– These interventions should consider the psychosocial and cultural understandings of pregnancy and childbirth, as well as existing traditions, birth expectations, and perceptions of control, need, and quality of maternity care.

Key Role Players:

– Village health teams (VHTs): Community volunteers who can mobilize and sensitize communities to actively participate in utilizing health services.
– District and local community leaders: Provide permission and support for the study and potential interventions.
– Research team: Comprised of senior investigators, including epidemiologists, an obstetrician, a medical anthropologist, a maternal/reproductive health expert, a nurse, and a health informatics specialist.
– Research assistants: Social scientists who conducted the interviews and transcribed the data.

Cost Items for Planning Recommendations:

– Training and support for village health teams to effectively mobilize and sensitize communities.
– Development and implementation of interventions to address barriers to healthcare utilization.
– Monitoring and evaluation of the interventions to assess their effectiveness.
– Communication and dissemination of findings and interventions to relevant stakeholders.
– Potential costs for additional research or studies to further explore and validate the findings and interventions.

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 interview study design, which provides valuable insights into the psychosocial and cultural factors influencing birthing choices for unskilled home delivery among women in Southwestern Uganda. The study was conducted in a specific district with a high maternal mortality ratio, which adds to the relevance of the findings. The sample size of 30 women is relatively small, but the researchers used a purposive sampling strategy to include women with varied knowledge and experiences of pregnancy and childbirth. The interviews were conducted in a private setting and digitally recorded, which enhances the credibility of the data. The data analysis followed an inductive content analytic approach, which allows for the emergence of themes and categories from the data. However, it would be beneficial to include information on the demographic characteristics of the participants and the specific villages included in the study. Additionally, providing more details on the interview guide and the process of coding and analyzing the data would further strengthen the evidence. To improve the evidence, the researchers could consider increasing the sample size to ensure a broader representation of women in the region. They could also provide more information on the selection criteria for the villages and participants, as well as the steps taken to ensure the validity and reliability of the findings. Finally, including direct quotes from the interviews in the abstract would provide concrete examples of the psychosocial and cultural factors influencing birthing choices.

Resumo

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.

Materiais

N/A

Inovações

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

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to remote villages and provide essential maternal health services, including antenatal care, skilled delivery, and postnatal care. This would bring healthcare services closer to women who have limited access to health facilities.

2. Community Health Workers: Training and deploying community health workers, such as Village Health Teams (VHTs), to provide education, support, and basic maternal health services within their communities. These community health workers can act as a bridge between the community and health facilities, promoting awareness and encouraging women to seek skilled facility delivery.

3. Telemedicine: Utilizing telemedicine technologies to connect women in remote areas with healthcare professionals. This could involve virtual consultations, remote monitoring of pregnancies, and providing guidance and support during childbirth. Telemedicine can help overcome geographical barriers and provide timely access to healthcare services.

4. Addressing Cultural Beliefs and Norms: Developing culturally sensitive interventions that address the psychosocial and cultural factors influencing birthing choices. This could involve community engagement programs, educational campaigns, and working with local leaders and influencers to challenge misconceptions and promote the importance of skilled facility delivery.

5. Improving Facility-Based Care: Enhancing the quality of maternity care in health facilities to address women’s dissatisfaction with facility-based care. This could involve training healthcare providers on respectful and compassionate care, improving infrastructure and equipment, and ensuring the availability of essential supplies and medications.

6. Financial Support: Implementing financial assistance programs to alleviate the financial burden associated with facility-based delivery. This could include subsidies or conditional cash transfer programs that incentivize women to seek skilled delivery services.

7. Transportation and Ambulance Services: Improving transportation infrastructure and access to ambulances for emergency obstetric care. This would ensure that women can reach health facilities in a timely manner during labor and childbirth.

It is important to note that these recommendations are based on the information provided and may need to be further tailored and evaluated in the specific context of rural southwestern Uganda.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to implement a multipronged approach to address the barriers to healthcare utilization. This approach should aim to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery.

Some specific interventions that can be considered include:

1. Community education and awareness campaigns: Conducting community-based education programs to provide accurate information about the benefits of skilled facility delivery and the risks associated with unskilled home delivery. These campaigns can address misconceptions and cultural beliefs that influence women’s birthing choices.

2. Strengthening healthcare infrastructure: Improving the quality and availability of maternity services in health facilities, particularly in rural areas. This can involve training healthcare providers in emergency obstetric care and ensuring that facilities have the necessary equipment and supplies for safe deliveries.

3. Engaging traditional birth attendants (TBAs): Collaborating with TBAs and integrating them into the healthcare system to ensure that they have the necessary knowledge and skills to provide safe and hygienic deliveries. This can help bridge the gap between traditional practices and modern healthcare.

4. Empowering women: Promoting women’s autonomy and decision-making power regarding their reproductive health. This can involve providing information and resources to women, empowering them to make informed choices about their birthing options.

5. Improving transportation and access to healthcare facilities: Addressing logistical barriers by improving transportation options and ensuring that healthcare facilities are easily accessible to women, especially in remote areas.

6. Addressing financial barriers: Implementing strategies to make skilled facility delivery more affordable, such as providing subsidies or insurance coverage for maternal healthcare services.

By implementing these interventions, it is hoped that more women will choose skilled facility delivery, leading to improved access to maternal health services and a reduction in maternal mortality rates.

AI Innovations Methodology

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

1. Community-based education and awareness programs: Implement programs that educate and raise awareness among women and their communities about the importance of skilled facility delivery, the potential risks of unskilled home delivery, and the available maternal health services.

2. Strengthening healthcare infrastructure: Improve the availability and quality of healthcare facilities, especially in rural areas, by investing in infrastructure, equipment, and skilled healthcare providers. This includes ensuring the availability of emergency obstetric care services in health centers.

3. Addressing financial barriers: Develop strategies to address financial barriers that prevent women from accessing skilled facility delivery, such as providing subsidies or financial assistance for transportation, facility fees, and other related costs.

4. Engaging traditional birth attendants (TBAs): Collaborate with TBAs and traditional leaders to promote safe birthing practices and encourage referrals to skilled healthcare providers when necessary. This can be done through training and capacity-building programs.

5. Mobile health (mHealth) interventions: Utilize mobile technology to provide information, reminders, and support to pregnant women and new mothers. This can include SMS or voice messages with important healthcare messages, appointment reminders, and access to teleconsultations with healthcare providers.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population group that the recommendations aim to benefit, such as pregnant women in rural areas of southwestern Uganda.

2. Collect baseline data: Gather data on the current utilization of maternal health services, including the percentage of women opting for unskilled home delivery, reasons for their choices, and barriers they face in accessing skilled facility delivery.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the identified recommendations and their potential impact on improving access to maternal health. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, financial resources, and cultural norms.

4. Input data and parameters: Input the collected baseline data, as well as relevant parameters and assumptions, into the simulation model. This may include data on the effectiveness of community-based education programs, the cost of strengthening healthcare infrastructure, the reach and impact of mHealth interventions, and the willingness of TBAs to collaborate.

5. Run simulations: Use the simulation model to run various scenarios that reflect the implementation of the recommendations. This can involve adjusting parameters and assumptions to simulate different levels of intervention effectiveness and coverage.

6. Analyze results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. This can include evaluating changes in the percentage of women opting for skilled facility delivery, reductions in maternal mortality rates, and improvements in overall maternal health outcomes.

7. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This can help improve the accuracy and reliability of the model’s predictions.

8. Communicate findings: Present the findings of the simulation study to relevant stakeholders, including policymakers, healthcare providers, and community leaders. Use the results to advocate for the implementation of the recommended interventions and to guide decision-making processes.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The steps outlined above provide a general framework for conducting such a simulation study.

Autor

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1155/2020/6596394

ISSN: 20902727

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations

Study Countries:

Uganda

Study Design:

Cross Sectional Study, Exploratory Study, Grounded Theory, Phenomenological Study

Study Approach:

Qualitative

Participants Gender:

Male & Female

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